Clinic redux

Last Friday I shadowed an outpatient neurology clinic as I do once or twice a month; here are the highlights.

1. Childhood narcolepsy. This is diagnosed using a sleep latency test; abnormally quick decent into slow wave sleep indicated narcolepsy. Unfortunately, the normative data for children doesn't exist so it can be hard to definitively diagnose. An EEG is also a good idea to rule out seizures.

2. Autism. I've never seen autism to this degree before; the appointment was because of an increase in obstinate behavior. The child was barking intermittently and would lunge for any paper he saw (to eat it). He was pulling the threads out of his sweater and eating those too. The parents looked haggard and completely worn out; dad would jump at the slightest noise. Three clinicians saw the boy together to determine whether antipsychotics should be started or whether the current medications should simply have their doses tweaked.

3. Refractory status epilepticus. An adopted child who has failed five different kinds of anticonvulsants. In the last two weeks there have been no seizures, but the week prior there were two: 75 and 90 minutes in duration. An MRI and overnight EEG are on the table as the first step towards consideration of neurosurgery.

4. Cerebral palsy. Not usually something we see unless it's part of a larger issue, which, in this case, it was. We just don't know what the larger issue is. The part I want to bring up is that the leg muscles can get tight and force the knees to turn inwards. This realigns the hips; if left uncorrected, the hips can become painfully and permanently displaced.

5. Absence seizures with syncope. I have now met two children with this seizure type: they lose consciousness for the duration of their seizure. Invariably they are worked up by cardiology first and when they don't find anything, they send them to us and we hook them up to an EEG.

Daffofils

They evoke the strongest memory of school in England.

Why so popular?

It mystifies me that the hands-down most often keyword-searched page on my blog is this post from July 26, 2006. It is far and away the most frequently visited page of my blog.

It turns out that if you google the words "screwdriver" and "chest," my blog comes up first. Cool.

Choosing a School

I am sitting in the law library (view from my chair, right) working on my biochemistry term paper on dentatorubral-pallidoluysian atrophy (DRPLA), but my mind keeps wandering. I have now heard from all my medical schools and must begin choosing where I want to spend the next four years. I have narrowed it down to three at which I have been accepted: Michigan, Mt. Sinai or UPitt or two at which I have been waitlisted: WashU or UPenn.

I am content to live in any of the above cities and they will all cost me about the same amount of money, so how do I choose? I am so paralysed by the decision that I have actually asked several of the attendings I know at the hospital to rank them for me (which they did: Upenn got 3 votes and WashU got 1 for the top spot).

I think what makes it so difficult is that I would be happy at any of these schools. All of them set me up well for the future; there is no wrong choice. I am extremely fortunate to be in this position and I recognize that. But I still have to choose. And I am still stuck.

In the meantime, this paper still needs to be written. Back to biochem.

Neonatal pre-op MRIs

One of the research studies I am involved in at the hospital includes performing an MRI immediately prior to the heart repair surgery of TGA and HLHS babies*. The baby we studied yesterday was oversized (due to mom's diabetes), but otherwise stable. The MRI revealed PVL,** which we have seen in 20% of patients prior to their surgery, and also a temporal lobe hemorrhage. We immediately called the surgeon to the MRI suite and a discussion ensued: what is the bigger danger - delaying the heart repair or potentially enlarging the bleed (the surgery would involved heparin, a blood thinner)?

We decided to delay the surgery and re-image the child in a few days to re-evaluate.

Sitting in on that discussion reminded me why I want to be a doctor. I've been losing the faith a bit with all the paperwork that is my job recently and this year long illogical waiting game of frustration that is applying. It was nice to have a reminder; hopefully I will get another one this Friday in clinic.

- - -
*TGA = Transposition of the great arteries. The aorta is connected to the right ventricle and the pulmonary artery is connected to the left ventricle, creating two independent circulations.
HLHS = Hypoplastic left heart syndrome. The left ventricle fails to form and the aorta is small and insufficient. Once the ductus closes, there is no systemic circulation.
**PVL = Periventricular leukomalacia, a white matter injury that occurs in pre-mature babies and is thought to be associated with mild cognitive problems.

Tragic

When I grow up

Now that I am settled on becoming a physician, the next logical decision is what kind of physician I want to be? Granted, there are rotations in third year to help me decide. I can shadow practitioners to make an informed choice and then, of course, I must match in the specialty I hope for. But what am I hoping for? Surgery? Emergency medicine? Pediatrics?

My colleagues that the hospital have their opinion: surgeon. My friends in their internships have theirs: neonatal intensive care.

But the best way to solve this problem is clearly to take some form of internet quiz. So I took the Medical Specialty Aptitude test on the University of Virginia Health System website. Apparently, my top 5 specialties are:
1. Nephrology
2. Thoracic surgery
3. Aerospace medicine
4. Plastic surgery
5. Pathology

I no longer put any faith in internet quizzes.

Postscript to Mr. Jobs

My computer was returned to me, however it was not fixed. Additionally, there were four notches on the optical drive that were not there when I brought the computer in for servicing. While the return invoice lists two "parts or services used," the optical drive needed three attempts to eject the first disc I put in.

I must now send my MacBook back in. Since I cannot do this at the moment (I need it for school and work), I have opened a case with AppleCare and will send it in April. How many times I must I send it in before you either a) successfully fix it or b) replace it?

Regards,
S

Dear Mr. Jobs

I have owned a series of Apple products over the years, but my most recent purchase (A MacBook) has caused me more headache than any PC I ever owned.

Shortly after buying it, it began leaking battery acid. There is no Apple store in Philadelphia and the Support team did not want to mail a toxic product so I had to ask someone to drive it into New Jersey for me to swap it for a new computer. No one at Apple transferred the Applecare to the new serial number so several months later when the hard drive spontaneously failed I had to spend a day on the phone proving that the policy covered this new machine.

The hard drive was replaced and Apple thoughtfully replaced several of the case panels as well. However, the panel that includes the optical drive was warped so when I got the computer back, it no longer ejected discs. I was in the midst of exams (and there is no Apple store in Philadelphia) so I waited three weeks until I could get to NYC to take it to a genius bar. Ruth (the genius) couldn't fix it in the store but she assured me that as a bounce-back repair it would be covered and I should have my computer back in 7 days.

It's day 5 and I just checked my status online. Apparently the repair has been on hold (since March 11, it's now the 13th) and no one called me, so I called Applecare. I spoke with Dan and Kendra and neither could tell me anything other than "wait for the depot to call you, they might not cover this repair."

I'm flabbergasted. Apple took it upon themselves to repair a part that was not broken and now, after a botched repair, won't fix their mistake. This is the third time this computer has needed repair! I need my computer to do my schoolwork and pay my bills - if there was a problem or delay, why did no one at Apple contact me?

I am purchasing a new computer this summer for medical school and the experience with this latest MacBook (less than 2 years old!) has forced me to seriously reconsider my stance on PCs. They might be equally much trouble, but they are much cheaper. If the product and service are going to be this poor either way, I might as well save my money.

Mr Jobs, I'm very disappointed. I think Apple makes innovative products, usually worth their higher prices. But apparently the quality and service are inverse to your company growth.

Please, fix my MacBook and send it back!

Medical School Update

Because no, the process is still not over.

Applied: 23
Interviews: 13

Of the schools who gave me interviews:
Withdrawn: 2
Waitlisted: 2
Accepted: 5

Of the schools who have accepted me, I have declined 2.

As you can tell, I'm still waiting for 4 replies. I will be rejected by the 10 schools that didn't interview me (I received 6 of those letters already).

Deadline for the final decision: May 15th.

Yummy!

We were talking about oatmeal chocolate chip cookies all day so when I got home I just had to make some. I didn't have any brown sugar so I used white sugar and maple syrup instead (and added a little extra flour) - they came out very moist and chewy... yum!