Valves go with ventricles

Hypoplastic Left Heart Syndrome (HLHS).

HLHS is a congenital cardiac malformation that falls under the heading of "single ventricle" defects. Essentially, the baby is born with only one functioning ventricle that must supply (actively or passively) both the body and the lungs. They also fall under the coloquial heading of "blue babies."

Typically HLHS babies will have a poorly formed left ventricle, mitral valve, aortic valve and proximal aorta. In order to promote delivery of blood to the body, the ductus is kept open by administering prostaglandins and in some cases the foramen ovale will be enlarged (in the cath lab or the OR).

Surgical repair for this condition is done in three stages: a Norwood procedure (with central shunt) shortly after birth, a hemi-fontan or bi-direction Glenn a few months later and eventually a full fontan at 2-3 years. Pictures and explanations of those in a later post. Sometimes the right heart cannot cope with the strain and transplantation needs to be considered.

HLHS occurs more frequently in boys than girls and has an overall prevelence of roughly 4 in 10,000 live births.

On a more personal note, a child I visited often in the hospital made it to her hemi-fontan, but her heart couldn't cope with the stress. She was on the transplant list for months and recently received her new heart. I was able to watch them close her chest three days post-op (in major cardiac surgery on infants they generally delay sternal closure) and she is growing stronger daily.

On feeling stupid

I have been cramming physiology, anatomy, histology, pathology, biochemistry and pharmacology into my head since August 4th 2008 and I am not one tangible iota closer to being able to effectively treat patients. It's not that I haven't learned anything, it's just that most of what I've learned is foundational. It's like building a house: when you drive by a newly laid foundation it doesn't look like much progress despite a terrific amount of work.

Yesterday I shadowed on the pediatric cardiology ward. This is a leading candidate for the kind of physician I want to be in the future and a field in which I have been published for clinical research. I didn't expect to keep up with the residents and fellows, but I thought I'd get some of it... maybe 10%?

Try less than 1%. About the best I could manage was knowing what the acronyms stood for. I knew why they wanted albumin levels and I correctly identified respiratory acidosis. But I couldn't tell you that the pleural effusion was protein or why, what the difference between a surgical and pigtail chest tube was, why you would withhold anti-fungals on the febrile baby with mediasteinitis, why a triple lumen catheter was better than a double, which port you put the guide wire through when changing a central line or what a 3/4 Fontan was. It was intense, thrilling and terrifying. How am I supposed to get from what I know now to being responsible for a pod full of patients like that?

Plenty of people dumber than me have become good physicians. I find myself repeating that a lot lately. I too will learn it and master it. But it was certainly a hip check to see just how long the road ahead is.

To end on a high note... I loved the day on the PTCU anyway. Despite feeling cluess most of the time, I loved it there. It's a great mix of medicine and procedures, acute care with repeat patients, interesting problems and enough good outcomes. One day my life is going to be amazing.

Watch where you're mowing

We recently had a lecture on bioterrorism within our infectious diseases sequence. One of the potential diseases that could be used as a weapon is Tularemia, a not-too-deadily infection caused by Francisella tularensis. It has a low infective dose, does not spread human-human, but you would feel like crap for a while. The Soviets were accused of using it and the US even researched its use as a weapon in the '50s.

Anyway, what I think is much more interesting is the outbreak that occurred in Martha's Vineyard in 2000. The CDC documented cases of people getting sick from lawn-mowing. Apparently, they mowed over nests of infected rabbits, aerosolizing the infected rabbits and inhaling the bug. That's right. The people of Martha's vineyard got sick from aerosolized bunnies.

It was then published in the Journal of Clinical Microbiology.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1233993

A spirochete song

My professor sang this to us in lab. Then he played a CD of his son's band performing it. It was originally printed in JAMA on Jan 31, 1942. Can you guess the disease?

There was a young man of Black Bay
Who thought syphilis just went away,
  And felt that a chancre
  Was merely a canker
Acquired in lascivious play.

Now first he got acne vulgaris,
The kind that is rampant in Paris,
  It covered his skin
  From forehead to shin,
And now people ask where his hair is.

With symptoms increasing in number,
His aorta's in need of a plumber,
  His heart is cavorting,
  His wife is aborting,
And now he's acquired a gumma.

Consider his terrible plight--
His eyes won't react to to the light
  His hands are apraxic,
  His gait is ataxic,
He's developing gun-barrel sight.

His passions are strong, as before,
But his penis is flaccid, and sore,
  His wife now has tabes
  And sabre-shinned babies--
She's really worse off than a whore.

He aches from his head to his toes,
His sphincters have gone where who knows,
  Paroxysmal incontinence
  With all its concomitants,
Brings forth unpredictable flows.

Though treated in every known way,
His spirochetes grow day by day,
  He's developed paresis
  Converses with Jesus
And thinks he's the Queen of the May.

It's syphilis.

spilled milk

I've alluded to the idea that the last month hasn't been the happiest in my personal life, which is true. And while I'm now managing to be honestly happy most of the time, I still have hours/days when I just feel achingly sad. I have found though, that when I get into one of those moods that stepping back a bit helps. Yes, it is appropriate and natural that I am sad, but the man I met who lost his arm, his son and his wife in the same week has much more to bear. The parents who had to withdraw care on their 3.5 year old son have lost so much more than me. It doesn't invalidate my own grief, but it certainly puts it in perspective for me.

it's not art school

One of the curricular elements here involves students visiting a family with a chronic illness several times over the course of two years. We then form small groups and create an interpretive multi-media project expressing common themes in chronic illness (as well as writing a series of reflective essays). While the visits are enjoyable and certainly lead to reflection on what it must be like to live with a chronic health issue, this is medical school not art school. During the most difficult sequence of the M1 year I am expected to come up with an interpretive art project?!

My two partners and I have decided to create artwork using the board game Life. We are going to remake the game board and glue it and other related game pieces to a giant posterboard. It's supposed to represent that illness is not really in one's control and that it affects all facets of life on a longitudinal scale. Or something like that.

When we proposed the idea to our class there was a certain amount of horror: you are going to make a game out of chronic illness? Crap. We hadn't really thought that through.

The best projects are then chosen to be displayed at a reception that all the families (and medical students) attend. I'll put up $20 that our remake of Life is not chosen.

Rest in Peace

I would like to take a moment to honour the memory of a 3 year old boy I knew in Philadelphia. He recently passed away due to GI complications and a genetic illness. I met him several times over the two years I was there and his whole family were warm and wonderful people.

The End of Anatomy

We had our anatomy closing ceremony today. After seven months and 32 labs of dissection, we have completed the anatomy curriculum. The occasion was marked by a series of awards, given out by the legend himself, Dr. Burkel, for the best anatomy students. I received recognition for setting up the practice exams for every sequence (with my colleague Zach).

One of the body donors had written a letter to the students who would be dissecting him and it was read to the whole class. It was a poignant and appropriate moment, but it was nevertheless awkward. While I try to be respectful of the body I worked on (I never cut of random body parts for fun or put him in strange poses), I simply cannot think of him as a living, breathing man while I'm sawing off his cheekbone or cutting his genitals in half.

Anatomy was a rite of passage, but I'm not unhappy it's over. It's important and valuable material, but it's simply not my favorite subject. I will miss the anatomy faculty, they are truly great teachers and interesting people.

Histology is also over, but that seems less momentous. Onwards to histopath! Only two sequences left... infectious diseases and development (and some clinical weeks in between). Two more months, then I'm an M2!

Positive Framing

My dad likes to send me links to interesting articles he finds online. Recently I received one about Japan's health care problems (which I didn't read) in a journal that also had an article on characteristics of successful women (which I did read). Apparently these women exhibited something called "positive framing."

"Positive framing and positive thinking... are two different notions. The latter tries to replace adversity with positive beliefs. The former accepts the facts of adversity and counters them with action."

This, I think, sums up my last few weeks very well. They have been extremely turbulent and somehow, three days ago, my mind pulled the plug on the purely emotional reactions and kicked me into action-mode. It's not that everything is suddenly okay, but that I have accepted what is and decided on actions that will eventually result in a restoration of my usual level of happiness.

And I have to say, when I dried my eyes and took stock of the life I have, I was really grateful. I have wonderful, supportive friends who were there for me, the respect of my peers and professors and lots of interesting opportunities ahead of me.

I'm certain I didn't choose the easiest road, but I (still) think it's the best one for me. Besides, you can't "live to the point of tears (Albert Camus)" without actually crying once and a while.

Pediatric Cardiology #1: Healthy Heart

I recently began working in clinical research again; with the Congenital Heart outcomes group. The study I'm working on has a much wider ranger of diagnoses that my previous work so I'm brushing up on my pediatric cardiology (in all that spare time medical school leaves). I thought it might be an interesting topic to share here, so this post is a primer on normal functioning (I did the drawings).

Unfortunately, most of the diagrams you see in books are functionally correct (ex. above), but not anatomically helpful. If you open up someone's chest (from the front, ie anterior or ventral) you do not see two ventricles sitting side by side. Instead, you see something more like...

You can see immediately that rather than a right-left orientation, the heart is really more front-back (anterior-posterior). Also, the ventricles are not so much "on top" as they are to the right. Which brings me to another point, we name everything by the patient's orientation. Thus, the right ventricle is the patient's right side, not yours. The whole heart sits slightly to the left of midline in the chest and its apex (point) is roughly beneath the left nipple.
The way blood flows through the two interconnected circuits - systemic (body) and pulmonary (lungs) - is frequently disrupted in congenital heart disorders. Normally, blood returns from the body through the superior vena cava (SVC) and inferior vena cava (IVC) into the right atrium (RA). As the right ventricle relaxes (diastole) it fills with blood from the right atrium. This is accomplished through a pressure difference between the ventricle (low) and the atrium (high), which opens the tricuspid valve. When the ventricle is full, the pressure will be higher than the atrium, pushing the valve closed (creating unidirectional flow). The ventricle contracts (systole) and blood enters the pulmonary trunk (through the pulmonary valve). The pulmonary trunk divides into a right and left branch to the right and left lungs. Each of these eventually becomes a capillary bed, which drains into small veins, which drain in to the 4 pulmonary veins. The pulmonary veins drain into the left atrium. As the left ventricle relaxes it fills with blood from the left atrium (same process as right ventricle, except the valve is called the mitral valve). When the left ventricle contracts it sends blood into the aorta (through the aortic valve). From the aorta blood goes all over the body and returns to the heart via the SVC/IVC.

There are two structures unique to babies' hearts: the foramen ovale and the ductus arteriosus. The foramen is a hole in the wall (septum) between the two atria. It's open and birth and normally closes in the first few days of life. Failure to close is called a patent foramen ovale (PFO) and can ultimately lead to congestive heart failure. The ductus is a vessel connecting the pulmonary trunk to the aorta. In fetal life it's used to bypass the lungs and it too usually closes soon after birth. Both of these conduits allow for mixing of blue (deoxygenated) blood and red (oxygenated) blood (which is a normal person is bad).

Summary: SVC/IVC -> R atrium -> (tricuspid) R ventricle -> (pulmonary valve) Pulmonary system -> L atrium (mitral) -> L ventricle -> (aortic valve) Aorta -> systemic circulation -> SVC/IVC

Key Points:
1. Ventricular filling is accomplished (almost entirely) through pressure differentials
2. The valves closing properly is important for unidirectional flow
3. There are two conduits for shunting blood from the right heart to the left: the foramen ovale and the ductus arteriosis
4. The pressures in the right heart are normally much lower than those in the left

If there are any questions, let me know and I will attempt to clarify. I only gets more complex from here!

Silk Road Project concert

I went to a classical concert last Saturday of the Silk Road Project. It was absolutely phenomenal. It's a company founded by YoYo Ma (yes, he and his cello were there) that incorporates instruments and musicals styles from all over the world and across many periods in time. It's a sort of classical-jazz-world-improvisation type of fusion that's unlike anything else I've heard. They've recorded a few albums that are on itunes (audio on their website too); I recommend giving it a glance and if they come to your city, go and watch it live.

I also got to hear YoYo Ma say the phrase "Go Blue!"

Frustration

Medicine is an interesting career in that it has very specific points at which you are forced to make a choice about what you want. The quintessential one is match day; there is a specific date on which everyone finds out what residency (and where) they will complete. For the current M4s, match day is this week. Medicine is also unique in that you are told where you will go - you don't get to weigh offers and choose one. You interview, you state your preference, and you hope to god you get what you want.

I have a lot of friends outside medicine right now trying to change jobs or get into graduate school and many of them have mentioned they envy the structure medicine provides. The next few years of my life are basically planned for me, but I find that terrifying. What if I can't make myself attractive to a residency program I want? What if I get stuck in a city I hate? What if I choose the wrong residency type (ie peds vs. surgery)?

I feel as if I have given up so much to do this, to be a doctor, and it doesn't end. I gave up a financially better career (banking) in a phenomenal city (NYC) to spend two years in night school just to apply to medical school. Now I'm living in a place I don't really like that's far from family and friends because it will give me the best chance at one of my top residency choices. I don't have the time (or energy) to play tennis or read books anymore and I can't keep a relationship together. I can't even make it to a friend's wedding or my 5-year college reunion. What do I have to give up next?

I know that what I'm doing is the best investment for my future and that I truly want to be a physician and yes, I am aware that eventually, when this is all done, I will have job security and a decent income (well... that depends a little on Obama...). I guess I just wish I was a little happier now. It's all well and good to plan for your future, but I seem to forget that I have to live in the present.

.... 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