Friday, August 30, 2013

WILTIMS #25: Hello kidney!

Long day today - histo lab, histo lecture, anatomy, anatomy lab, activities fair, and an anatomy review session.

As usual, anatomy lab was fun. We dug our way to the kidney (an organ that was described in a previous edition of our textbook as shaped like a kidney bean...) which is surrounded by layer upon layer of protective fat and fascia. I then got to bisect the kidney with a knife the length of my forearm. Overkill? Never.

At the activity fair I was actually helping run a club booth with some other first years who also were somehow handed off an entire club at a 15 minute meeting with a third year yesterday. The club is the Cancer Education and Awareness Program... Project? I don't even know our name! When I wasn't manning our table, I roamed around and joined a dozen or so club mailing lists that I will probably not have time for.

One of the cool things about med school is that the clubs aren't just for runners or chess players, but also for aspiring radiologists and neurosurgeons. We'll see how much I can take advantage of these groups, but it's still exciting nonetheless.

TIL: The developing fetus actually pees out the bulk of the amniotic fluid.


Thursday, August 29, 2013

WILTIMS #24: What'd we do wrong now?

Today we continued our excavation of the abdomen in anatomy lab. We partially detached the liver, were yelled at for doing it wrong, tied off the top and bottom of the small intestine, were yelled at for doing it wrong, removed the small intestine from the mesentery, were yelled at for doing it wrong, and dissected the stomach.

We have five different instructors for anatomy and, in the past week, our end of the room has been watched over by a rather brusk and confrontational surgeon. We've learned not to take offense to his constructive criticism, because absolutely everyone is treated the same way. If anything, it's bonded the students together as we laugh off any negative comments once the instructor moves on to the next table.

Later we had a lecture teaching us what our responsibilities will be as future mandated reporters of child abuse (TIL: Unlike most other states, NY doesn't mandate reporting of abuse to the elderly or dependant adults. Let's get with the program! But I digress...). We were then warned of the many many ways to commit medical fraud and the dramatic career ending punishments that are rendered on the perpetrators.

Lastly, I have gotten involved with a cancer education club that goes to local high schools to...educate high schoolers about cancer (surprise!). The idea is to complement DARE-like programs by teaching not just the pitfalls of peer-pressure and substance abuse, but to dive into the science behind cancer. Maybe if more people understand how carcinogens like cigarettes cause cancer, rather than taking our word that they do, they can make good informed decisions to live healthier lives.

TIL: When trying to describe anatomical features, we somehow always turn to food comparisons. Duodenum contents? Pesto sauce! Jejunum section? Sausage links! Greater omentum? Caramelized beef jerky with a teriyaki glaze!

The FBI can confiscate all of an office's medical records if the practice is under investigation for fraud. If the doctor needs the records for patient care, the FBI can even charge the office a per page fee to get copies made.

The new ICD-10 medical classification list that goes into effect next year in the US will have over 68,000 different diagnosis codes.

Tuesday, August 27, 2013

WILTIMS #23: On the shoulders of giants

Yesterday, one of our professors told an interesting anecdote during his lecture on the liver. His story started in ancient Greece - in the time of Hippocrates, the father of medicine. At the time it was believed that all body fluids were some combination of the four humors: sanguine (blood), choleric (plasma), melancholic* (clotted blood) and phlegmatic (mysterious off-white substance). Now before you dismiss this as crazy pseudo-science from 500 BC, you must understand the basis for the idea.

Note the illustration of stratified
blood serum at the top right
Physicians of the Hippocratic school would take a blood sample from their likely aristocratic patient and allow it to sit and settle. When it had, they noticed four layers (the four humors). Makes sense so far... However, when they looked at a healthy person's blood, they only saw 3 layers. The enigmatic phlegmatic humor was only present in people with fevers, certain illnesses and in pregnant women.

This is actually amazingly good science. The bloodletting they prescribed for this was less than brilliant, but given that we wouldn't discover the identity of the phlegmatic humor for over 2000 years, I'm willing to let it go.

It turns out the whitish substance is actually fibrinogen clotting factors produced by the body's inflammatory response. Even today, we test for this quality in blood. It's called an estimated sedimentation rate (ESR) test and it was actually the principle indicator of my recovery from lymphoma (and it's the nerve wracking number I wait for at every checkup).

How does all this relate to the liver? The fibrinogen protein is actually made in the liver after stimulation by interleukin-6. Why did my professor tell us this lengthy story? In the 1980s, he was the co-discoverer of IL-6.

TIL: Very little, especially of interest. Let's go with: Amacrine cells are the only nerves that have no axon and they are only found in the retina.

WILTIMS #22: Quickie

Twas a long day with way too much information, but as it's already late, I'll just leave you with a couple quick items and fill you in more tomorrow.

TIL: The term hypochondriac actually quite literally means "pertaining to the upper third of the abdomen." This is from the greek roots of hypo- (under) and chondro- (cartilage) referring to the cartilaginous lower rib cage. The word has come to mean an excessive worry about one's health because physicians of antiquity attributed many ailments to that region of the abdomen. Over time hypochondria became a catch-all term to describe any unexplained conditions, and later to describe people with illnesses that no one can find evidence of.

The rectum actually drains blood via two totally separate venous blood tracts. This becomes important in regard to colorectal cancer, because if the tumor drains blood into the vena cava, metastases will show up in the lungs. If, however, the tumor drains to the portal vein, the metastases will primarily collect in the liver and only secondarily make it to the pulmonary capillaries.

The spot on the skin where one makes the incision for an appendectomy is called McBurney's point.

Sunday, August 25, 2013

My time of day...

Yes, this was actually taken a few days ago as evidenced by the phase of the moon
It's a beautiful night and I'm out for walk. This is the medical education building, where I spend most of my time during the day. The glow from the top floor is the skylight windows of the anatomy lab. This is one of the few medical schools that doesn't hide their cadavers in the basement. Between the natural lighting and the well-ventilated high-beam ceiling, we really are spoiled with our lab. Bonne nuit everyone!

Saturday, August 24, 2013

WILTIMS #21: Guts

The anatomical informational onslaught continued today. The abdominal cavity is at a whole 'nother level of complexity as compared to the thorax. I bet you can name all of the organs in the thoracic cavity. Got 'em? The heart and lungs. That's it. The abdomen/pelvis? We've got the stomach, liver, gallbladder, pancreas, spleen, small intestine, large intestine, appendix, bladder, and either the uterus and ovaries or the prostate - not to mention the intricate webs of blood vessels, nerves, and mesentery tissue.

Though I have little grip on the terminology yet, it was a blast to get back to exploring our cadaver in lab today. After reflecting the anterior peritoneum (folding back the last tissue covering the abdominal cavity), there was suddenly so much to see! That was the best part really; there was very little we had to dissect today and plenty of time to explore.

Coolest sounding name of the day: the epiploic foramen of Winslow

Longest names of the day: the posterior superior pancreaticoduodenal artery, the anterior superior pancreaticoduodenal artery, the posterior inferior pancreaticoduodenal artery, and the anterior inferior pancreaticoduodenal artery

Yes, these are chicken gall bladders, but you get the gist
TIL: The gallbladder is green! Not kinda sorta greenish, but Saint-Patrick's-Christmas-tree-bell-pepper-salad green.

The appendix is surprisingly unassuming for a thing that can quickly and painfully kill you.

Thursday, August 22, 2013

WILTIMS #20: OB/GYN?

Today we had histo lab, and a bunch of less than interesting cell bio classes. But after classes, I decided to attend an OB/GYN interest club meeting. I'm not really thinking of going in to that specialty at the moment, but I've heard some good things about the field, so I thought I'd give the club a look.

When I was interviewing at another school, I was given the campus tour by a 4th year who was going into OB/GYN and he had this was his reasoning: OB/GYN is the perfect specialty because you get a little bit of everything. You have the intimacy of family medicine (and then some), but you are less concentrated on diabetes and heart disease. You get the drama of emergency medicine, only concentrated because all of your cases are actually life and death. You are mostly concerned with internal medicine, but you get to do legitimate surgery fairly regularly. Unlike other fields where patient compliance is a big problem, your patients are incredibly receptive because they're hormonally charged with protective instincts (his words, not mine).

The speaker today was Dr. Howard Blanchette who is apparently quite the bigwig in OB/GYN. He shared his story and why he chose this specialty and then shared stories to exemplify the joys and sorrows of the field. My takeaway: it seems like an wildy rewarding career, if you can handle the ups and downs. He also described the dramatic change in gender ratio of OB/GYN physicians from when he was in residency (95% men in 1972) to today (80% women), and stressed that it doesn't matter so long as you are skilled at your craft and listen to your patients.

TI reL: I'm pretty sure I have heard this before, but as I apparently learned very little of interest today, I wanted to share this anyways. Duchenne's muscular dystrophy is caused by the dysfunction of the dystrophin protein (biologists can be rather dry in their naming of things (though there are exceptions)). The discovery of dystrophin marked the first time scientists were able to find the cause of a disease by first finding a genetic mutation, sequencing the normal gene, and then finding the protein for which the gene coded.

Wednesday, August 21, 2013

WILTIMS #19: Abdominal beginnings, chlorine and Mondor disease

Today we started our new anatomy block - the abdomen, pelvis and perineum. It seems the trend with this class is to throw as much information at us as possible at the beginning of any particular subject and then go back and approach the material at a more reasonable speed from multiple angles in the subsequent weeks. So, today was rather overwhelming. 

For our Community and Preventative Medicine class we had a lecture from the Commissioner of Public Health for Westchester County. Lots of amazing stories. Takeaways: vaccinate religiously; chlorine is your friend, lead is not; close the pool first, ask questions later; don't use a wet vac to clean up vomit (unless you like aerosolized vomit).

TIL: Mondor disease is a stupidly scary sounding condition resulting from the sclerosis and thrombophlebitis of a subcutaneous vein of the anterior chest wall. The jargon is half the scariness so let's try that again in English: Not-that-scary disease results from the hardening and inflammation of a vein just below the skin in the chest due to a blood clot. This is far more common in women and can be caused by complications of breast surgery or simply wearing too tight a bra. No treatment is typically required as the clot will dissolve on its own.

Tuesday, August 20, 2013

WILTIMS #18: It's arteriOsum!

Trachea of a cat and ear of a deadman...
      Histology slides or potion ingredients?

Ligamentum arteriosum!...
      Vestigial fetal arterial shunt or obscure wizard hex?

Perhaps it's just that I've recently been rereading the Harry Potter series, but med school seems a lot like Hogwarts. We receive letters from the school inviting us into a world few get to see. We are given a list of expensive supplies that we need to buy before classes start ($600 for an oto/ophthalmoscope?!). We even have to procure a wand - or at least a tool derived from a wand of sorts. Most people don't realize that the stethoscope, when it was invented in 1816, started as a long wooden tube that was pressed between the patient's body and the doctors ear (for the Ollivander fans out there: pine, no core, 11½ inches).
Laënnec and the Stethoscope. Painting by Robert A. Thom (1915–1979), c. 1960.
And as with Harry Potter, if you know a bit of Latin you can get a hint as to where things are headed. What is Prof. Lupin? A werewolf (lupus* = wolf). What's stored in the fetal cloaca? Excrement (cloaca = sewer). In either case, sometimes ignorance is bliss.

TIL: Omphalocele is when the intestine of a baby is found in the umbilical cord. This is actually normal up to a certain point in development, and can be surgically repaired if present at birth.

Also, in some babies, the umbilical cord is still connected to the small intestine as a vitelline fistula and feces will come out of the baby's belly button. Again, this is easily surgically repaired.

Finally, situs inversus is when all of a person's internal organs are reversed. The heart and stomach are on the right, the liver and appendix are on the left, etc. This arrangement, though very rare, is totally compatible with a healthy life.

*The disease lupus also has a murky connection to wolves or french hats named after wolves. One of those... so says the interwebs...

Monday, August 19, 2013

WILTIMS #17: First test

Well, that was... unremarkable.

We had our first exam in medical school today, following a weekend where everyone stressed and studied and stressed some more. Yes, we have been exposed to a ton of material over the past two weeks and yes, we've never competed with classmates of this caliber before. But, as the proctoring professor said, this was the first of hundreds and hundreds of tests we will complete before we are board-certified, practicing physicians. Also, might I add that we've all taken untold hundreds of tests to get to this point! We must be good at taking tests, or we wouldn't be here. And if that doesn't calm the nerves (and don't get me started about nerves... vagus, phrenic, splanchnic, intercostal, left recurrent laryngeal...), a timorous med student can always fall back on the old adage: what do you call the person who graduates last in their class from medical school? Doctor.

All of that said, I actually think I did pretty well. I really enjoyed the lab practical, a test the likes of which I have never taken before. They arrange all 28 cadavers* in three rows and line the walls with diagnostic images (x-rays, CT scans, MRIs). Each body has one anatomical feature highlighted (with pins, string, probes, etc.), which we must then identify from ~5 multiple choice options. We have one minute at each station and then must move on to the next. The whole circuit (with some rest stop stations to allow for more students to be in the room at once) took about an hour.
One of the more labor intensive example questions
The written test was much more typical. 70 questions, an hour and a half, a scantron and a trusty number 2 pencil. Definitely passed, definitely didn't ace it. On to the next one!

*In an earlier post, I said there were 27 cadavers. No, they didn't kill off one of the students or anything. Unbeknownst to me at the time, there had always been a 28th cadaver that a 4th year student dissects before each lab, as an example of the proper procedure.

Saturday, August 17, 2013

Study Aid


Studying the vessels of the heart is a pain in 2D, so I wrapped a sock in paper to make a 3D model. Much better!


WILTIMS #16: ALL the stories!

The past two days were a whirlwind of activity, broken up by very little sleep. Yesterday began with histology lab and three histology lectures. Histo continues to cement itself in my mind as a nice time to take a nap and/or catch up on my social media - I'm looking at you Reddit (no, literally, I have Reddit open in my other tab).

Luckily, our anatomy lecture that afternoon was given by an incredibly entertaining radiologist that bribed us with candy (that never stops working, apparently). The talk was on the basics of reading x-rays and CTs, specifically in the thorax, as that's all the anatomy we are expected to know so far. One of our first exercises was to try to identify a structure from the three cross-sectional images below.
We tried to apply the skills we had just learned to make educated guesses. Looks like a tube. White is dense material; black is air. Deformed bone? Nope. Calcified vessel of some sort? Wouldn't be that thick... Messed-up kidney? Is "messed-up" a medical term?

I'll let you think about it. Clue: you all know this structure. Click here to see the answer.

We also discussed the common pathological findings of the anterior mediastinum, which are remembered by the dumbest mnemonic ever: the 4 Ts. These are thymoma, teratoma, thyroid, and terrible lymphoma. Does that last one seem like a bit of a stretch to you, too? Here the professor asked our class of ~200 to raise their hands if they knew someone who had had the most common lymphoma: Hodgkin's. (I raised my hand along with probably a quarter of the class). She then asked us to keep our hands up if they were immediate family. At this point I gesture to her that I had in fact had it myself. You could tell she was stoked that I was there to make her point. 

Dr. R: What's your name?
Me: Christopher
Dr. R: I don't want to violate HIPAA [class chuckles], so how about you share with the class.
[passes me the mic]
Me: Actually, I had Hodgkin's lymphoma.
Dr. R: And how are you doing?
Me: Pretty good.
Dr. R (to class): He looks pretty good to me.
Dr. R (to me): Would you call lymphoma "terrible?" [I tentatively shake my head] I mean I'm sure it wasn't fun and you probably called it many nasty things, but you survived, yes? [I nod]
Dr. R (to class): You see? Lymphoma, as far as cancers go, is very treatable and almost never terrible. This is why I hate that mnemonic.
Dr. R (to me): Here, take some candy and pass it down your row.

So cancer perk #56: Get's you candy for sharing in class!

After this we had smaller group sessions to go over the radiology. Our group was taught by the chief radiology resident from Westchester Medical Center, who was very nice and down to earth.

Then it was off to the grass in front of the pediatric trauma helipad for the first flag-football games of the season! The medical, public health, and physical therapy students field over a dozen teams each year for a weekly co-rec flag-football league.

I helped ref the first game with one of my roommates (please always be nice to volunteer refs in any sport) then took the field with people who I had mostly just met to battle it out. After a promising 12-12 halftime score, the other team got on a streak and eventually won 42-12. The game was not as lopsided as it would appear though, because any goal scored by a girl is double points and their girls were quite good. Lots of fun and a good study break.

My roommates and I made it back to the apartment at around 8. It was here that my day took a turn for the worse and I only have myself to blame. I (being stupid) decided to sign up as a scribe for the school's student run lecture transcription service. We type out notes from recorded audio tracks and are paid for our time. The only problem with this plan is that I can't type quickly - at all. It took me 6 hours to type and format a 35 minute lecture. Never again.

Today, we had another clinical skills session where we learned more of how to do a physical exam. To be clear, all we're really learning at the moment is how to look like we know how to do a physical exam. For instance, today we learned how to palpate (touch), percuss (tap), and auscultate (listen to) the neck, chest and back. Theoretically, this would enable us to examine the lungs and heart, but as we have no idea what normal or abnormal sounds like yet, we're really just playing doctor - albeit very accurately. A common, if disconcerting, motto for clinical learning is "Fake it 'til you make it."

In the afternoon, we had our last anatomy lab before our first test on Monday (both a written and practical). It turns out that our cadaver continues to be the best body in the room. Our person's heart had an interesting and surprisingly common birth defect, a patent foramen ovale. This is when there is a hole between the right and left atria of the heart. During fetal development, this shunt allows the oxygenated blood from the umbilical cord to skip the developing lungs and perfuse the rest of the growing body. Usually the shunt closes after birth, but in 30% of people a small hole persists into adulthood. As long as it's small enough not to dramatically affect the heart's circulation, the person would likely never even know until someone listens with a stethoscope (like we did this morning!) and hears the associated murmur (unlike we did this morning...).

TIL: A flail chest is when 3 or more ribs on one side of the chest are each broken in two or more places. This causes a portion of the chest to move in paradoxical motion. (Warning: The video is... unsettling)

Friday, August 16, 2013

WILTIMS #15: Scribing stinks

Apologies. Today/yesterday was crazy. I'll update on all of it tomorrow.

TIL: The reason a tension pneumothorax (pressured air in the chest cavity) is so dangerous is not actually the deflation of the lung, but rather that the crumpled lung and/or mediastinum puts pressure on the vena cava. This deprives the heart of blood and dramatically lowers blood pressure.

Wednesday, August 14, 2013

WILTIMS #14: $$$, cut first, and Lympha

Today was less than exciting. No labs, few interesting lectures, and a two-hour financial planning course. The takeaway: if we manage our $250,000+ of debt half-decently, we're gonna be poor for a good 10 years, then we will be very well-off thereafter. Woot.

Click to enlarge

The amount of money made by physicians in the US is absolutely ridiculous, and is yet another symptom of how broken the system is. And though doctor salaries are not even close to the biggest contributor to health care costs, they should still be addressed at some point. I know some people who would never have gone into medicine without the incentive of high compensation awaiting them down the road, but I know even more who would do it regardless the pay, because, let's face it, it's an awesome job. It's supposed to be about helping others, right? </rant>

TIL: One surgery you really don't want to need to have is an exploratory laparotomy, which is essentially when the a surgeon has no idea what's going on in the abdomen, so they cut it open to have a look. This really only happens after a traumatic injury where there is extensive damage and/or bleeding with inconclusive radiological findings.

Also, the lymphatic system (e.g. lymph ducts, lymph nodes, etc) is named for Lympha, the Roman god of fresh water. This is because when early anatomists were trying to map out the circulation of the body, they noticed that the structures that would later be known as lymphatic ducts did not contain blood, but rather a clear liquid that sprung from the tissues like a mountain spring. Ironically, this is some of the dirtiest fluid in the body, where pathogens are collected and destroyed and cancer metastases often spread.

WILTIMS #13: Kali-Ma!!!

We had class today from 9-5. Ugh. 2 hours of histology lab, 3 hours of histology lecture, a ½ hour of anatomy lecture and finally 2½ hours of anatomy lab.

In histo lab we learned, in theory, how to differentiate between the various epithelial cells of the body. Do I remember what differentiates gall bladder epithelium from stomach mesothelium? Not a chance. But I can differentiate veins from arteries, find capillaries amongst the kidney's tubules, and differentiate simple from stratified layers, squamous from cuboidal cells, and columnar from pseudostratified organisation. I'm calling that progress.

Histo lecture was mind-numbingly boring. This was in part because the professor, though obviously brilliant, could use work on his oratory skills, and partly because much of the material was basic review for someone with my cell biology background.

The afternoon, however was worth the wait. We left off yesterday having cracked the chest, removed the lungs and exposed the heart from the pericardium. Today we removed the heart and dissected the coronary arteries, coronary veins, the right atrium, and the posterior mediastinum (the area behind the heart). The heart is an amazing organ and it has a difficult architecture to wrap your mind around with 2D images. Holding it in your hand and manipulating it is by far the best way to really grasp (ba-dum-ch) the intricacies of its structure and the comparative orientations of its components.

Finally, upon returning to my apartment-dorm hybrid I made my first real, involved meal since moving in - tomato-spinach risotto. Om nom nom.

Intelligent design my ass...
TIL: 70% of people have right-dominant hearts, meaning their posterior interventricular artery is supplied with blood from the right coronary artery. In another 10% this artery is supplied by the circumflex coronary artery (itself a branch of the left coronary artery) making the heart left-dominant, while the remaining 20% are co-dominant, with an anastomosis (reconnection of separate parts of a branching system) connecting the two sources.

Also, the larynx is innervated by the vagus nerve (tenth cranial nerve), but only after the vagus reaches all the way down to the aorta. There the recurrent laryngeal nerve splits off and heads back up and out of the chest, all for no particular reason. Essentially, the nerve gets tangled around the great arteries during development - and that's if everything goes to plan.

Tuesday, August 13, 2013

WILTIMS #12: Pass the bone saw!

After my first real weekend (o, sweet respite!), it's back to the trenches. The second years have all returned and I even played a pick-up flag football game with some of them. Alas, our weekend was not all fun and games. The first years were all required to attend a CPR/BLS course that took most of Sunday. Relatively painless, if a bit tedious. The highlight was the mass-beating of babies - which in context was totally socially acceptable as a demonstration of how to dislodge an object from a choking infant.

This morning we had our most intensive anatomy lab yet. Normally, each body is shared by two groups of four students, each of which dissects one half of the body in turn. For labs in which we must work on one of the body's unilateral structures, like the heart and brain, we instead join with the other group and work together. Today we removed the anterior rib cage (the front of the chest) to expose the chest cavity. We then removed the lungs and made a window to the heart within its pericardial membrane.

Rib shears.
Opening the chest was weird and awesome and did I mention weird? We snapped the ribs one by one with a tool that looks like a cross between plant shears and scissors. They make a crispy crunchy sound not unlike ripping apart a dry tree branch. We then used a bone saw to cut through the manubrium and inferior sternum (respectively, the top and bottom of the breast bone). After using any and every tool we could find to clean up the cuts, we finally removed the rib cage. Twas satisfying.

Later in the day we had another lecture by a career surgeon. His lectures are usually light on required information and heavy on amusing anecdotes. We learned how to auscultate (listen (why do we need all these fancy words again?)) to heart murmurs from the various valves. On Friday, I believe we will be practicing this ourselves.

Finally, this evening I went into the anatomy lab after hours for the first time. It's really nice having around the clock access to the cadavers, not that I plan on communing with them alone in the wee hours of the morning...

TIL: My hands may never stop smelling like dead people.

Friday, August 9, 2013

WILTIMS #11: Stethoscopes and scalpels

After a brutally didactic lecture day yesterday, we reveled in a practical-heavy schedule today. We had a fairly straightforward dissection of the muscles covering the ribcage. The most interesting part of it was the copious use of blunt dissection (prodding, prying, spreading and ripping with your gloved hand). It's a very odd feeling having your hand entirely enveloped by cadaverous tissue - in this case, feeling the contours of the ribs and intercostal spaces while the pectoralis major muscle presses on the back of your hand like a glove. Next week, we crack the ribcage!

Part two of the day was our first practical clinical section and we broke out our stethoscopes and blood pressure cuffs for the first time. This class is going to be interestingly intimate as the term progresses. Today we were just taking vitals on each other (or at least trying too) but next week we will be doing the cardiac exam in our mixed gendered groups and the women have been asked to wear sports bras. One of my roommate's groups only has one girl, so is everyone going to need to examine her? Who will she examine to train on the female body? Interesting.

Lastly, we had an entertaining new instructor for our anatomy lecture today. He is a practicing general surgeon with experience in cardiology. It was a very different perspective from the PhDs and internal medicine physicians that had been teaching us so far. Every few minutes we got another example of surgical technique that we were promptly told to forget until third year.

TIL: If the CT scanner breaks and you need to diagnose a probable aortic dissection, you can do an endoscopic ultrasound of the esophagus to look at the descending aorta.

Thursday, August 8, 2013

WILTIMS #10: Just like spreading butter!

Sorry,  about yesterday's lacking post! This should more than make up for it.

Yesterday was our first fully-fledged anatomy lab and it turns out I'm pretty handy with a scalpel! We had a fairly simple task for the day: skin the chest and then remove the subcutaneous tissue (gross yellow fat) to expose the deep fascia (thin clear membrane) just above the musculature.

There are 27 cadavers for our class and as with any population, we have people of all shapes and sizes. The lady two down from us is frighteningly skinny and there is one man whose enormous belly you can see from across the room. Our gentleman was a very healthy weight which made everything that much easier for our group. Under the leathery skin is about a quarter inch thick layer of fat. The fat has a consistency something like if you filled the juicy flesh of an orange or grapefruit with congealed butter. So it's packaged in tubes of connective tissue that will shred with very little pressure, producing a slimy, oily yellowish substance. You can use either forceps (big tweezers) or a hemostat (clamp-able tweezers) to pull away the skin while using scissors of a scalpel to pry away the tissue below.

Most groups had a hard time separating the skin from the fat and afterward, simply scraped the fat off both the skin and underlying fascia, throwing the fat away (to be stored for cremation at the end of the year). We, however, did such a good job separating the skin from the fat that we were dared by the instructor try to keep the subcutaneous tissue in one giant piece. Unlike with the skin, we couldn't use any grasping tools because the fat would shred under the pressure, so we did it by hand. It was a real pain to get started, but once we had a handhold, we made quick work of it. When the instructor came back around he quite loudly said, "Wow!" The other professors who came by had similar reactions and said that they should use ours as an example. Needless to say, I was very proud.

Today, was a whirlwind of histology and anatomy terms. I thought I'd share with you some of the more daunting examples: syncytiotrophoblast, pericardiacophrenic artery, and lamina fibroreticularis.

TIL: The heart has a fibrous skeleton that surrounds and provides structural support for the various valves. In some large mammals, like the ox and elephant, it is partially ossified, becoming actual hard bone.

Wednesday, August 7, 2013

WILTIMS #9: Headache

I had a fantastic time in anatomy lab today, but as I'm feeling a bit under the weather at the moment, I'll have to update you tomorrow.

TIL: Gloves don't protect your hands from smelling like dead guy. Relatedly, lunch is less appetizing after anatomy lab.

Tuesday, August 6, 2013

WILTIMS #8: Firehose and histology lab

Studying in med school is often compared to trying to drink from a firehose. After years of trying to get here, I feel like I've just climbed out of the desert in search of a drink only to nearly drown in the torrent of water.

I'm not the only one though. After returning from lunch today, our professor paused to comfort us. Apparently as we left the auditorium that morning, we looked so shell-shocked that he felt he needed to say something to calm us. Yes, it is a lot of information, but we will be covering it several times, from multiple perspectives and we are not expected to know it all right away.

Later, we fired-up our microscopes in our first histology lab class. It's been a while since I've used one (how many years ago was Intro Bio again?), but it is fun to have actual slides rather than digital ones on the computer. And boy do we have slides! ~95 actually.

TIL: The vast majority of the time you want to have the microscope's condenser as raised as possible. One of the few exceptions to this rule is when you want to detect reflective features. As an example: arteries and veins can be easily and conclusively differentiated by the reflective intima layer of the arterial wall.

Monday, August 5, 2013

WILTIMS #7: Day one/birthday


First and foremost, I want to assure you that every picture on this blog is taken with permission of the appropriate parties. As my first example, the photo below was permitted by an anatomy professor - so long as the bodies were covered, I was covered. Therefore, I'm sorry, there will be no gross anatomy pics in this blog (get it?! gross anatomy... ya know cause it's... oh nevermind).
Anyways, it's day one and I'm already out of breath. It's not that we did tons today - actually, today was fairly mellow. To begin with, we "met" our cadavers - 27 bodies in total. Mine is male, old, and thankfully not obese (others were not so lucky).

Later we got to meet our first live patients too! A panel of 6 actual patients invited by our professors came to give us advice on how to be better doctors and to take our questions. It was a good bunch with complex diagnoses and complicated relationships with the medical system. Here are some of the takeaways: 
  • Don't treat patients as numbers/diagnoses
  • Listen
  • At minimum, glance at the pt's history before entering the room
  • Go that extra mile to show a personal investment
  • Impressions are made immediately
  • Be present for every patient and don't bring the baggage of the previous patient into the room
After this, we had to take a diagnostic test for biostatistics, on which we all confirmed that we don't remember statistics. What's variance again? r²? z-score? chi square? It's like high school French: I recognize that they are valid words, but I couldn't use them in a sentence if my bibliothèque depended on it ...or something like that.

Finally, I took myself out for a celebratory Taco Bell birthday feast (and brought my anatomy books, of course), and started to prepare for tomorrow, when we really dive headfirst into the material. And boy do we. We have 90 slides for anatomy for tomorrow alone. So with that, I will take my leave to flip through a few more slides before bed.

TIL: The 2nd ribs can be located by palpating for the sternal angle and moving laterally.

Friday, August 2, 2013

WILTIMS #6: White Coat Ceremony day

Today, in front of 800 people, I was helped into a white coat for the first time. Kind of an overwhelming experience. Seeing my reflection in a window afterwards, I couldn't quite come to grips with the idea of me finally wearing this symbol of all my hard work and stubbornness, which will someday become a symbol of trust for my patients. My patients. Weird. It's a privilege and a challenge that I am honored to work to earn.

My next update will be Monday after we actually begin!

TIL: Idealism and realism must be balanced in the field of medicine.

WILTIMS #5: NYHS AIDS exhibit

Today we took a field trip (on far too little sleep) to the New York Historical Society in Manhattan, to visit an exhibit on the first five years of AIDS in New York. After a private, hour long introduction by the curator of the exhibit, we were guided through the displays by about ten of our medical faculty. They both explained the significance of part of the exhibit and told  personal stories about their first encounters with AIDS.

Each doctor's experience had made a lasting impression. One ran a birthing clinic in Africa that in 1972 had made great strides in improving child survival rates, only to be closed by 1974 when all of the 100+ babies born were born with and shortly died from undiagnosed AIDS.

Another talked about the total lack of universal precautions for the health prescribers (the concept didn't exist until the AIDS crisis) and yet out of irrational fear, the patient was wearing a full gown, mask and goggles, while she wasn't wearing gloves.

My favorite story was from the Chancellor, whose first experience was from his residency training at Harvard. While walking through a lab, he came across three eminent physician researchers looking at a slide under a microscope. As he approached he heard them mutter things like, “Hmmm, it's not good," and, "Quite ugly." Upon hearing the resident approach, they turn and tell him to look into the 'scope and ask him what he thinks. And like any sensible person would do, he says, “Oh, doesn't look good."

He inquired about what he had just seen to find that this was “that new thing from San Francisco." At the time, in 1981, the disease was neither identified nor named.

TIL: When George Washington was being vetted for the first presidency, he was criticised as a choice because the old lesions on his face from a childhood bout of small pox. Detractors said that he would never be embraced as a leader because of the stigma of his blemishes. At the time it was literally true - no one shook his hand.