.... and I'm back

I know it's been a while since I've posted regularly. I can give you all kinds of excuses (medical school is a lot of work, I've been traveling a lot), but honestly it doesn't mean much unless you see me post regularly again... so let's see if I can manage that.

The first year of medical school (to date) has been a little different than expected - there is a lot less patient interaction than I was accustomed to while being in the hospital. It's a lot more social than you think - we work really hard but we go out a lot too. On the other hand, it's also cost me more than I expected and I don't likemy geography at all. I love my school and my classmates, but I don't like living in Michigan (too far from friends/family/big cities). Some notes:

1. I hate anatomy. It takes up a lot of time and it's not that interesting. Apparently this means I am unlikely to become a surgeon.

2. I love video-taped lectures and flex-time quizzes. It gives me autonomy and allows me to pursue activities outside of class.

3. I was in a swing dance performance



4. I am doing clinical research again (on HLHS). I didn't realise how much I would miss it, so it's really nice to be able to work that into my schedule.

5. I am a MedBuddy coordinator - we pair medical and nursing students with children in the hospital for extended stays. The students visit the kids 3-4 times a week. I also have a MedBuddy - cutest little girl ever!

6. Two of the papers I was co-author on have been published!

7. During an a series of alternative medicine lectures I received a massage and had an acupuncture needle put in my hand (it feels weird).











8. I went to the inauguration










9. I went to Rome, Florence and Paris for spring break










Ok - I think that covers some of the cooler tidbits. I will keep you updated!

Pre-dissection reflection

I've finally put my finger on why dissection is making me feel a little hesitant and slightly uncomfortable. It's not cutting into a body per se; I was fine while watching surgeries. It's the fact that dissection is intentionally destructive. Surgery is about health and healing, about the best interest of the patient and their future functionality and quality of life. Dissection is about complete and total deconstruction with no consideration for the future. It feels like a violation because this is invasion with no intent to heal; it's taking apart a human lego set piece by piece knowing that not only can you not put it back together, you're not even going to try.

On the one hand I want to be respectful, this was a person and even in death they deserve to be treated well. On the other hand, I want complete detachment and dehumanization because otherwise, how do I (inexpertly) flay someone's father/brother and just go home and make dinner?

In some cases, the body donor willingly gave themselves, but the family did not. How do I look those family members in the eye, knowing that what I'm doing is against their wishes? I don't really want to meet the family (now); that will only make it harder to keep cutting. Do they really want to meet me? Do they really want to see who is doing this to their father/brother? Will I look undeserving to them? Not what they imagined a future doctor will look like?

Passed: Patients & Populations

I have successfully completed the first sequence in medical school: patients and populations. It was comprised of three threads: Medical decision making, pathology and genetics. If anyone ever told you there is no math in medical school, they were wrong. Bayesian probabilities anyone?

It was actually quite a nice starting sequence because we had no anatomy or histology - giving us more time to get to know each other and the town. Once a week we had patient presentations, for example, the mother of a son with Down Syndrome, a woman who has tested positive for Huntington (but is still clinically asymptomatic) and a girl who was diagnosed with colon cancer at 22.

Speaking of extra-curriculars... the first football game was Saturday! You have definitely not seen a tailgate until you've seen a big 10 tailgate. Wow.

We have met our cadavers though and dissection begins Sept 2. Histology Sept 3. Next sequence: Cells & Tissues.

(one photo is from the tailgate, the other is karaoke night)

What the doctor said

a poem by Raymond Carver, for our consideration as we think about the relationships we build with patients.

He said it doesn't look good
he said it looks bad in fact real bad
he said I counted thirty-two of them on one lung before
I quit counting them
I said I'm glad I wouldn't want to know
about any more being there than that
he said are you a religious man do you kneel down
in forest groves and let yourself ask for help
when you come to a waterfall
mist blowing against your face and arms
do you stop and ask for understanding at those moments
I said not yet but I intend to start today
he said I'm real sorry he said
I wish I had some other kind of news to give you
I said Amen and he said something else
I didn't catch and not knowing what else to do
and not wanting him to have to repeat it
and me to have to fully digest it
I just looked at him
for a minute and he looked back it was then
I jumped up and shook hands with this man who'd just given me
something no one else on earth had ever given me
I may have even thanked him habit being so strong

I'm going home with the DJ...

Because she's my roommate...

<---

Medical concepts made easy: #1

According to Dr. R, it is very important that we understand the concept of diapedesis; a phenomenon observed in the inflammatory response. So important, in fact, that he acted out the apparent struggle of a neutrophil trying to squeeze through an endothelial cell to attack a microbe (played by an M2). Popping across the stage in apparent success he yelled "I have diapedesed!" Later that night I felt the very same struggle when trying to cross a packed dance floor to get a glass of water. I couldn't help it, when we finally made it to the edge of the crowd, I turned to my roommate and said "I have diapedesed!"

Scientific definition: White blood cells migrating across the endothelium due to injury or trauma.
Real world analog: Crossing a packed dance floor due to thirst or heat.

Remixed: No Handlebars

[to the tune of Handlebars by the Flobots]

I do dissections with my Netters guide
My Netters guide
My Netters guide

Look at me, look at me
Hands in a guy who's so sad to be
DECEASED
And I'm an M1 student
Though my stethoscope's brand new you'll see
I can hear your heart go boom ba-boom
I can show you how to take blood pressure
I can take a full patient history
And I an almost tell you what it means
I watch all the lectures at double speed
And I take all my quizzes in the LRC
I know all the types of cell necrosis
And I'm proud to be at Michigan
Me and my friend saw a surgery
Me and my friend can place an IV
And guess how much we sleep
I can treat anything you got cuz, see

I can hear a murmur with no stethoscope
No stethoscope
No stethoscope

I see your MI on the EKG
on the EKG
on the EKG

Look at me, look at me
Cuz I'm on call but I'd rather be
ASLEEP
In such a warm bed
Tired out with dictation to do
I won't make money in my residency
And I won't see my significant other
I'll be almost forty before I'm debt free
Almost a quarter million dollars
I will proscribe antibiotics
I will make your body function without your heart or lungs
I know how to check a reflex
And I can make you stick out your tongue, say ah
Doctors, surgeons and the patients
We all find insurance so frustrating
I see the slowing on your EEG
But no epileptiform activity

I can hear your problems but I'll never tell
But I'll never tell
But I'll never tell

I can thin your blood with IV heparin
IV heparin
IV heparin

Look at me, look at me
Learning and I won't stop
It feels so good to be an
MD, yeah a doc
My oath is global
My ethics secure
My profession noble
My job is to serve
I will hand out a million vaccinations
And give all my patients good explanations
And sew up so many lacerations
Perform post-surgical extubations
I can write a complete review of systems
Including your vital signs and
All of your medications in a list when
You get discharged and it's time to go

I can see your brain on the MRI
the MRI
the MRI

And I can stop the seizures with some Topamax
With some Topamax
With some Topamax

And I can fix blue babies with a full Fontan
With a full Fontan
With a full Fontan

Introducing Pre-Mortem

I keep a book of things I would like to do before I die. Some are little: own a pet (not yet). Some are adventurous: skydive (done it). The book reminds me of the cool things I've done and the amazing adventures I have to look forward to.

I began this long before that horrible movie "Bucket List" (which no, I did not and never will see). Over the summer I began making the list electronic in case anyone wanted to follow along. Each post is a different goal; I will update them with photos and stories as I accomplish them.

http://design42pm.blogspot.com

Orientation round-up

The first week of medical school is coming to a close and I thought I would run through the highlights. First, we were all coated and attended a rather awkward reception because no one knew anyone else. The chocolate-covered strawberries were delicious though. The next three days included an array of (rather boring) lectures acquainting us with the school, its policies and what was expected of us interspersed with some cool team building exercises and lots of provided food.

Thursday night was the traditional M1 bar crawl (the first day of class was also Thursday...coincidence... not exactly). We all wore pretty blue matching shirts and had drink specials at three bars in town. Pre-drinking chow at the Pizza House before shots and dancing and singing to Bon Jovi. Fun moment: asking directions from a law student. His reponse: what did you get on the MCAT?

Friday I missed the first hour of lecture (bad me) but did make it to a dinner party at a neighbor's house and a hip hop concert (6 acts!) in town. The DJ for the Blue Scholars is a phenom... I never thought I would hear Green Day turned into a hip hop beat, but it works.

Saturday we made a little mall trip, then a BBQ and a night of dancing at Live. Tonight will be Indian food for dinner... yummy!

Coated!

I have officially started medical school! I received my white coat and stethoscope from the Dean, stumbled my rather bewildered way through three days of orientation and am now in classes. I (already) have lectures and syllabi and assignments and quizzes... I am a medical student... weird.

School is modular, so every few weeks I will finish a module (organ system) and all its corresponding histology/pathology and anatomy. Year one is healthy organs, year two is sick ones.

First up: Patients & Populations (genetics) - 3 weeks.

Advanced civics

Since my last post about DC, I returned and managed to correctly identify the white house. I even took a photo of it (left).

I also hit up the botanical gardens, air & space museum, natural history museum, art museum, aquarium (ninja turtle, right), washington monument and climbed the rocks at Great Falls.

Not of historical note, I had the best tuna and salmon sashimi I've ever eaten (including in Japan) and went to a bar called "sign of the whale." Great name. I also spent a lovely evening eating chocolate chip cookies, drinking wine and watching Sideways. In that vein, I would like to note there are some perfectly good merlots.

Oh, and I saw the Dark Knight in IMAX. Phenomenal.

North, to Alaska!

Completing my North American tour (S: Mexico to N: Alaska, E: NY to W: California) was an active little jaunt through Alaska by boat. The best moment was climbing the Mendenhall glacier in Juneau, hands down, no questions. Yes, that's me to the left. We helicoptered up there (fantastic), trekked around and did a little climbing. We helicoptered back out just as the storms rolled in.

In Skagway we rode a gold rush era train up to the white pass summit and biked back down (cold!). In Icy Straight Point we drove ATVs up a mountain and ziplined back down (that's my brother and I in the photo) from an elevation of about 3000ft. In Ketchican we went salmon fishing, but somehow managed to catch two dogfish sharks. We let everything we caught go- for the karma.

Medical mysteries

Now that I've left one hospital and moved to another, I find myself reflecting on how many cases were left unsolved. Not untreated or unresolved, but without the foggiest clue as to an answer. The following are some examples:

1. Spinal inflammation. Patient presented with loss of propioreception in the feet, ankles and lower legs. CSF showed inflammatory markers. Treatment with high dose steroids provided mild, temporary relief. Five months later the inflammation is still present, though propioreception is now in tact at and above the ankles. High dose steroids, IVIg and plasmaphoresis had no effect.

2. Severe, sudden onset rhabdomyolysis with no concurrent trauma. Rhabdomyolysis is a rapid breakdown of skeletal muscle and is usually seen when there is a trauma. This patient had muscle breakdown products in her blood at levels usually seen only in crush injury (ie part of a building falls on you), but had done nothing more arduous than work out. Best guess... virus?

3. Adolescent onset of type 1 diabetes with concurrent peripheral neuropathy. Usually type 1 diabetes (the autoimmune, insulin dependent one) presents in childhood, so the age of presentation is unusual, but not unheard of. The concurrent peripheral neuropathy however, is rare enough that I was going to write the case up for a journal (but never got around to it). Neuropathy usually takes years of poorly managed diabetes to emerge.

4. An infant had a hemangioma on her sacral spine so an MRI was performed. The scan revealed several round growths in her spinal column. It was unclear whether they were also hemangiomas or if they were tumors. A spinal tap was inconclusive. It was decided to monitor the growths rather than attempt a biopsy at this point.

Boom-de-adda

I posted a couple of months ago about my "love of the whole world." Apparently, xkcd loves the whole world too. Boom-de-adda...

Straddling the Mississippi

The end of June found me down in New Orleans for a few days. Preservation Hall was probably my favorite experience - it's an old wooden room (no air conditioning) in the French Quarter where some old timers play jazz requests. Fantastic.

The strangest moment was definitely when we went inside the cathedral. First, the fire alarm went off. Shortly afterwards, a middle aged man with a cane started yelling at a man in the front pew who appeared to be praying. The middle aged man shouted "you won't speak to me in that manner, not in my cathedral" and waved his cane around. The other man just sat there. A third man approached, to mediate the situation. All three headed outside (we followed). A cop car pulled up and the cops arrested the man who had been sitting in the front pew and drove off with him.

There was no physical altercation and I can't think of anything a person can say that is egregious enough to warrant an arrest. It was all remarkably odd.

Another funny moment was when we ran under a roof overhang to hide from the sudden afternoon shower. Nearby there were several goslings and some grown swans and ducks. I guess the goslings didn't like the rain either because they came towards us. The parent geese were not so keen on that idea however, and we ended up fleeing from a large group of geese who were pooing/running/quacking at us.

A civic education

I spent a few days in DC and found out just how much I don't know. First off, it turns out the building pictured to the left is, in fact, the capitol building, not the white house. Oops. Second, the Library of Congress is not a library you can just read in (like the New York public library). Bummer. Third, I can eat and really like pesto. Yum.

Fourth, Pearl Jam has lots of awesome music I haven't heard. Well, hadn't - until I went to their concert. Amazing, even from the nosebleed seats.

Also in DC: Marvins (crowded), Mini Cooper (surprisingly spacious), sushi (excellent), the Hulk (mediocre) and Guitar Hero II on Xbox (solid fun).

Reverse clinical pathology conference

Today I went to my first reverse clinical pathology conference. It's reverse because rather than starting with the patient's presentation and moving forward in time, you start with the pathology slides and try to reconstruct the symptoms and diagnosis based on what you see under the microscope.

There are pathology rooms with multi-headed microscopes: 8-10 viewing stations connected to a single slide mount so everyone is viewing the same slide simultaneously. A pathologist usually "drives" and physician and fellows (and me!) sit around the other viewers. The pathologist loaded in stained, prepared slides of the brainstem, cerebellum, and cortex for examination.

Slide #1 cerebellum. The cerebellar cortex is made up of three layers: the molecular layer, granule layer, and Purkinje layer. In our slide there was no surface granule layer, indicating the cells had already completed their migration and the patient must have been at least 12 months of age. The Purkinje cells were dying, a classic hypoxia sign. We also saw evidence of infection in the meninges (membranes covering the brain) and the parenchyma (brain tissue) such as macrophages and perivascular cuffing.

In the parenchyma we noted neuronophagia: dying neurons surrounded by microglial cells. This pointed us towards considering a viral diagnosis. Bacteria can stay in the meninges surrounding the brain, but viruses are obligate cellular parasites and thus more likely to appear in the neural tissue itself. We examined the neurons for inclusion bodies, which are accumlations (not exclusive to viral infections) within either the cytoplasm (ex rabies) or nucleus (ex. herpes). Not all viral infections have inclusion bodies, but their presence, absence and type can help to identify the specific pathogen. In this patient there were no inclusion bodies.

Slide #2: pons (brainstem). We noted extensive liquefactive necrosis, leaving the tissue with a spongelike appearance. Basically, the neurons are dying and pockets of fluid-filled space are left where there used to be brain tissue (necrosis = abnormal cell death). The extent of the damage in this patient was severe, indicating a rampant infection and acute, considering the cell types present.

Slide #3: midbrain (brainstem). The substantia nigra in the midbrain was noted to be unpigmented. This area usually develops pigment between 3-5 years of age (and can be lost again in old age as part of a neurodegenerative process). This placed the patient's age between 12 months and 3 years.

Slide #4: spinal cord. Most infections have a regional preference within the nervous system; they don't invade all areas equally. Thus, looking at which regions are affected can narrow down the pathogens under consideration. In our patient, the anterior horn of the spinal cord was disproportionately infected, which led us to consider the enteroviruses (ex polio, Hep A).

Conclusion: The patient turned out to be 25 months old and died of a massive Coxsackie viral infection. Coxsackie virus (type B pictured to the right) is probably best described as a non-paralytic polio and it can affect other organ systems besides the central nervous system, most notably the heart and eyes.

Note: this case has been previously published so the details have not been altered. All photos used are from searching google images and are not the slides from the actual conference.

Employee appreciation day

It was Caribbean-themed employee appreciation day at the hospital today, complete with activities, free food, and dancing. We started by donning flowered necklaces (I wore mine as an armband), moved on to decorating flip flops, ate some fried plantains and mango popsicles and the daring among us got spray-on tattoos. The award definitely goes to Alana, for tattooing Gray's name on her leg - fabulous.

Wedding weekend in nyc

The weekend in New York City was punctuated by a few fun highlights, not the least of which was staying in my friend's rather fabulous apartment near Columbus circle.

The ceremony and reception had about three hours in between them, so a few of us decided to find a local pub and grab a beer. The watering hole we ended up in had no draught beer and the bartender was taking bets on the payphone for Belmont. There was, however, a pool table. James managed to clear the table in a single turn (he broke and the rest of us didn't touch a cue).

The reception involved some classic dances moves: soulja boy, the roger rabbit, etc as well as 12 courses of yummy food. The wedding cake was an ice cream cake - a choice I fully and wholeheartedly endorse.

Post wedding we headed to Manhatten for a drink. We managed to grab a bottle of champagne from the reception and brought it, and a stack of paper cups, to the bar. We tried to pop it and drink it asap so as not to get caught, but get caught we did. We smooth talked the manager into waiving the corking fee by ordering drinks and shots and stayed out into the early am.

Congrats Jeff & Joanna!

You know you have a problem when...

... you coworker buys you three pints for your birthday.