|Click to embiggen|
Thursday, October 31, 2013
Tuesday, October 29, 2013
TIL: ...the super complicated way that we manipulate our vocal cords. Explaining it would take too long for a blog post, so instead I give you a video of a quartet singing from the inside. Enjoy!
There are spillways on either side of the epiglottis (the flap at the bottom of the tongue that blocks off the trachea when you swallow) that allow you to constantly swallow excess mucus while breathing.
Whales sing underwater by moving air back and forth between their mouths and their stomachs through the vocal cords. You can try this at home by taking a modest breath, plugging your mouth and nose, and trying to make noise. Sounds pretty whale-like, doesn't it?
Topical anesthetics can be used to numb/paralyse the muscles of the larynx (say for a bronchoscopy), however they don't reach the superior and recurrent laryngeal nerves. These nerves innervate the muscles of the larynx but also sense distension of the aorta. A problem can arise when the brain, unaware of the scope in the throat, interprets an increase in pressure on the laryngeal muscles as sudden high blood pressure in the aorta. This can set off a dangerous reflex where the brain tries to lower the blood pressure leading to a heart arrhythmia and even cardiac arrest.
Prescribe lemon candy for salivary stones. The lemony acidity will cause the patient to increase salivary production and reduce stagnation and crystallization of the salivary fluid.
Monday, October 28, 2013
Saturday, October 26, 2013
|The salivary glands: #1 parotid,|
#2 submandibular, #3 sublingual
TIL: The parotid gland and pancreas are the only two glands that produce amylase, the enzyme that breaks down starches into sugar. The parotid gland secretes serous fluid, including the amylase enzyme, into the mouth via a duct that can, on rare occasions, become occluded causing the sides of the face to swell. This condition is easily confused with the mumps, which also results in the swelling of the parotid gland, but from the inflammatory action of the mumps virus rather than the obstruction of the parotid duct.
Seizures originating in the temporal lobe are associated with the perception of an strange smell. These seizures can be caused by radiation from the treatment of salivary gland cancers located in the parotid gland.
Friday, October 25, 2013
On the brief curricular side of things, we had yet another histology lab (only 2 more!). This time we were investigating the skin... and a monkey fingertip.
This afternoon I got to step back over to the patient side of medicine at my first appointment with my new oncologist. I was first seen by an oncology fellow* working under the main doctor. It was fun chatting with (and silently judging) someone who is, though already 10 years ahead of me, still completing his training. When my actual doctor came in, it was entertaining watching him simultaneously tend to me and teach his student.
After my appointment (everything looks good btw), I ran back to campus to play in our final flag football match of the season. We were crushed by a team of second-years, but they were such good sports that we still had a blast.
After the game, I quickly changed and headed back out to a neurosurgery interest group meeting. We met in the radiology conference room in the hospital and, unlike other interest group meetings I've attended, were greeted by not one, but easily half a dozen doctors, fellows and residents. The head of neurosurgery welcomed us and then a pediatric neurosurgeon presented on current interventional techniques for common maladies.
TIL: The skin contains three types of glands: two sweat glands and one that secretes an oily substance called sebum. This third secretion is released by a holocrine gland which emits its cargo by literally filling up until it bursts. Accordingly, your skin perspires sweat, oil and cellular debris.
A bone marrow biopsy is not indicated for a stage 2 Hodgkin's lymphoma patient (hopefully the fellow learned this too!).
When a cranial suture (the border between bones of dome of the head) fuses earlier than normal in a child, the head will elongate in the direction parallel to the suture. This is called craniosynostosis and doesn't usually cause and neurological deficits directly. But because children aren't generally as nice to a kid with a noticeably oblong head, if the defect was not corrected the child is almost certain to suffer socially and subsequently educationally.
Young children recover extremely well from cranial surgery thanks to their still-developing skeleton. A 6-month old could have the entire surface of the skull removed and grow it back within weeks.
Neurosurgery before good imaging techniques were invented used to be described thusly: For a hobby you can either do fishing, hunting or neurosurgery. Your prey never survives, but at least you can have some fun.
*For those unfamiliar with the ridiculously complicated nomenclature for students of medical education:
- 1st-2nd year of medical school → medical student
- 3rd-4th year of medical school → medical student/sub-intern
- 1st year of residency → intern and/or doctor
- 2nd-6th year of residency (usually 3-4 years) → resident and/or doctor
- 1st-4th year of fellowship (usually 2-4 years)→ fellow and/or doctor
Wednesday, October 23, 2013
|Click to triangulate|
Tuesday, October 22, 2013
Saturday, October 19, 2013
Friday, October 18, 2013
It's been an amazing, fun-filled day. I learned how to do an HEENT exam, how to use my $600 glorified flashlight, how to cut open a skull with an electric bone saw, and what the consistency of a human brain is. But I also travelled to see my significant other, so I'm deferring writing about my super awesome day until tomorrow. See you then.
Thursday, October 17, 2013
TIL: While motor innervation of the muscles for facial expression are supplied by the facial nerve (Cranial Nerve VII), the sensory input from the skin on the face is communicated via the three branches of the trigeminal nerve (CN V).
You haven't gotten all the way to the bone of the skull until the metal probe makes a "ping" noise when you tap it.
In the surprisingly lyrical words of my anatomy professor, the superior sagittal sinus is one of the main veins that drains the brain.
Tuesday, October 15, 2013
|My study-skull and my roommate with his|
|The sella turcica of the sphenoid bone|
First, for remembering the carpal bones of the hand:
Some Lovers Try Positions That They Can't Handle
Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, and Hamate
Second, for remembering the order of the anatomic entities that pass under the flexor retinaculum of the ankle:
Tom, Dick And Very Nervous Harry
Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and flexor Hallucis longus tendon
Saturday, October 12, 2013
|The reactions of teammates to Kevin Ware's broken leg (you've been warned)|
Friday, October 11, 2013
Thursday, October 10, 2013
Today I Remembered: ...why I'm doing all of this work.
In our small group session this afternoon, we had a guest instructor and we were asked to introduce ourselves and briefly say why we decided to be doctors. This prompt elicited a hearty mix of chuckles and groans from my classmates and myself because we had to answer this question ad nauseum during the application process, and hoped we were done with it for good.
As the circle approached my end of the room and everyone sheepishly said the same tried and true response ("I love science and want to help people."), I started to think. You know what? We aren't applying anymore, so we can say whatever we want. We're like retired politicians that can finally speak from the heart instead of from party lines. If I'm honest, what is my motivation?
My classmates moved too quickly for me to come up with a succinct response, so I barfed up some barely coherent line about my family and how the profession can be selfless. I'm still not sure where I was going with that. The class moved on and I put that thought on the backburner while I self-destructively criticized my inability to speak (normally not a weakness of mine).
My big activity for the day was way outside my comfort zone and I had been nervously looking forward to it all week. I signed up as part of GHHS NYMC Cares Week to volunteer at the nearby homeless shelter. A group of ~8 medical students would go give a presentation on diabetes and hypertension to the residents of the shelter. I was the only first-year to sign up for this activity and would be working with 2nd and 4th year students who, might I add, had already taken physiology, pathology and pharmacology and were thus much more reliable sources of health information than myself.
The older students turned out to be incredibly welcoming. They loved to reminisce about their first years and give tips on how to survive mine. When we got there we found that we wouldn't be able to use our Powerpoint presentation and would instead print out the slides to pass out to the residents. While we waited for the printer, we mingled in the activity room. Residents started to assemble and quickly grew restless waiting for something to start. As much as I like talking with the immeasurably cool 4th years, I felt more and more awkward ignoring the people we had come to (theoretically) help, so I went over and introduced myself to a particularly antsy older man.
We casually started talking and had a great conversation. It turned out that he was a cancer patient (like myself, for a time) but that he had refused to continue treatment after 10 years of chemo. I told him that I could understand his choice, and we commiserated for a while about nasty diseases, nasty doctors and nastier hospital food. By this point the rest of the medical students had followed my lead and dispersed amongst the residents and were engulfed in animated discussion.
The presentation began once the printouts arrived and almost immediately we began fielding questions. It seemed everyone in the audience had diabetes, hypertension or both - and the few who had neither were hypochondriacal enough to have questions anyway. And you know what? We answered every one of their questions. I could actually help real live people (and not just my mom over the phone)! True, I knew the least of all the students, but I still could chime in to clarify things and share the little I did know.
The highlight of the day for me was prefaced by an awkward moment where two residents asked questions at the same time. The more deferential of the two waited and was eventually forgotten amongst the continued discussion. After the presentation was over, I went immediately to that man and explained that I had not forgotten his question and that it was actually a really good one. He had originally asked if potassium was good to take for the cramps he developed in his legs while exercising (we confirmed this during the main Q&A), but had also heard that salt could help too. The sodium in salt is actually physiologically paired with potassium throughout the body. The only thing is, unlike with potassium which banana-haters might actually run low on, as unhealthy Americans we are never deficient in sodium thanks to our over-consumption of salty foods.
So, could sodium deficiency cause the cramps? Yes. Is that likely? Not really. Try a banana and some more water first. The man was incredibly thankful for both our time in general and for my extra effort to answer his question (and he told me so!). It was the first time I got to go out of the way for a patient - the first time I made a connection and established a professional trust with someone.
This is why I went into medicine. If I had to sum it up in a sentence, I might fall back on the application staple ("I love science and want to help people."), but it's something more than that. Something harder to describe but exceedingly more beautiful.
Tuesday, October 8, 2013
The problem with suturing blood vessels up to that point was that the standard technique called for clamping off both sides of the vessel and then trying to stitch first the top and then the bottom of the now flattened vessels walls. The reason this didn't work is that vessel walls are incredibly thin and fragile. The clamps irrevocably damaged the tissue and the surgeons couldn't suture one side without nicking the other, causing even more damage. The answer came in the form of the triangulation stitch, a method borrowed from sewers (as in one that sews, not one that collects feces) of fine silk tubes. They would use three small stitches placed equidistant around the tube to pull the tube taut, forming three flat sew-able surfaces that, when relaxed, formed a complete circle.
This technique made many now common surgeries and the entire field of transplantation possible, saving countless live. So why did I sale Carrel's story was complicated? His best friend was Charles Lindbergh, the famous aviator and later Nazi sympathizer. Together they invented the first perfusion pump, the precursor to the artificial heart, again saving untold lives. However, they were both outspoken supporters of eugenics and Carrel later moved back to France during the German occupation of WWII to work in high level scientific positions in the Vichy government. Thus, these were men with murky legacies, to say the least.
TIL: A good way to find reflexes on a seemingly reflex-less patient is to ask them to lock their hands and pull against their own strength as hard as they can. While the patient is distracted, you can whack them with the hammer with renewed success.
Saturday, October 5, 2013
TIL: Never give a vasoconstrictor with local anesthesia in the fingers. Vasoconstrictors are drugs that cause the tightening of blood vessels and they are often given with local anesthesia to help them stay in the patient's blood circulation longer. The problem with the fingers is that they only get blood and nutrients from two tiny vessels and the administration of a vasoconstrictor will cut off blood to the entire finger. If not corrected quickly, the tissue will die and the patient could lose the finger.
|Mini-Me and Dr. Evil|
The last tidbit that I learned today, came from a family member who had a recent brush with the medical field. A laminectomy, the removal of some or all of the back-most (or laminar) surface of one or more vertebrae, can be an effective late stage treatment for spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord. Fascinating if unpleasant stuff. Get well soon!
Friday, October 4, 2013
There was a fun point today where for the first time I learned something that someone had asked me about in the past few years of pre-med purgatory. They had a bump on their wrist and came to me because I was "the medical person" and I had no idea what it was. We made a solid guess based off some internet perusing and forgot about it. Today we covered synovial cysts of the wrist, one of which was in fact the cause of my friend's bump. It's a totally benign condition that can be resolved by, no joke, smacking the wrist really hard to pop the cyst.
TIL: The "anatomical snuff box" (pictured on the upper right on the beautiful hand of yours truly) is a groove on the forearm that received its name by victorian era snuff sniffers who found it a convenient to spot to place snuff while they put away their snuff box.
Injuries to the radial nerve can cause the arm and wrist to assume what's called the "waiter's tip position" (seen on the left).
A median nerve injury can be identified by asking the patient to try to make a fist and then looking for the "hand of benediction" (No, JPII didn't have a nerve injury; he is doing the namesake sign of benediction that happens to perfectly mimic the nerve condition).
Wednesday, October 2, 2013
We had to change into our white coats and professional attire for the second half of the day as we had the privilege of watching a sample patient interview by one of our professors of an actual patient. The patient was a kick in the pants and even though we were packed like sweaty alabaster sardines, we really enjoyed the lecture. Afterwards we broke up into smaller groups in the modular rooms upstairs to discuss the process of interviewing patients, specifically in regard to showing empathy.
I had a nice pair of experiences that I think beautifully show both my inexperience and potential. We were asked what we would say to a patient who we had just informed that she had mononucleosis. My first response was,
What's mononucleosis!? I feel like I know this... Is it a cancer? What has one nucleus? Who let me into this school anyway?Meanwhile, one of my classmates responds by saying that she'd ask about the patient's medical history and try to find out where she contracted it from. I'm still beating myself up:
How does everyone else know what this is!? We don't take pathology until next year!Then a second classmate takes a stab at it, saying that he'd want to find out what treatments are available and relay that to the patient since mono is treatable.
MONO!? How did I not know that mononucleosis is the full name for mono! Of course this disease isn't named the equivalent of "uno."
Hey wait, I know the answer to this and it nothing to do with the disease!"Anyone else?" my professor asked, clearly frustrated at the direction my fellow classmates had headed with the question.
I raise my hand. "Well, I think I would first try to reassure her that..."
"THANK YOU!" The professor abruptly cuts me off. "Reassurance is exactly the word I was going for." She goes on to explain how to best reassure patients after giving hard diagnoses, while I start to feel better about my mono mental lapse.
TIL: In the loosely transcribed words of our example patient: "There are only two people you don't lie to - your doctor and your priest... and your mom!" Noted.
"Yes, I meant to go down this abandoned hallway! I'm inspecting the... uh, light switches. Yep we're all good here!" [walks hastily back the way he came]Hopefully by the time I actually need to be in this hospital, I will be a smidge less lost than some of my classmates.
TIL: The canal of Schlemm is fun to say. I'm going to put it in the same category as the epiploic foramen of Winslow and the ampulla of Vater. Besides reveling in its euphonious name, I also learned it's location and function (apparently I learned the word euphony as well).
Schlemm's canal is essentially a drainage duct for the aqueous humor (gooey stuff) in the eye. If the eye is damaged and scar tissue ends up in the fluid, that tissue can collect in and block the canal, leading to an elevated intraocular pressure which is the most important precursor for the development of glaucoma. For anyone who's ever been to an optometrist, this is what they are checking for when they blow that puff of air at your eyes.
Our random sports fact for the day: when you see male gymnasts in the Olympics doing the Iron Cross skill (pictured on the right), the one muscle in their amazingly cut torso/upper extremities that they aren't using is the deltoid. The deltoid is used to abduct the arm (move it away from the torso), but gravity is doing all that work for the gymnast. He is in fact using all the muscles that normally oppose the motion of the deltoid (such as the trapezius and latissimus dorsi) while the deltoid, though bunched up from the position of the arms, lazily sits there waiting for gravity to stop stealing its thunder. Stupid gravity.
Tuesday, October 1, 2013
There is something I wanted to share with you guys that I didn't learn today, but was really impressed with while studying. The thymus is a primary lymphoid tissue, meaning it's a site for blood cell development. Specifically, the thymus is responsible for the maturation of T-lymphocytes. You may remember from your high school biology class (it's ok if you don't) that there are "helper" T-cells and "killer" T-cells. These cells are part of the body's adaptive immune system, which recognizes a threat (from bacteria/viruses/fungi) and both attacks it and remembers it for future reference.
The nifty part is that the discerning thymus essentially weeds out both the lazy and homicidal T-cells before releasing the mature, level-headed ones into the body. It does this in two steps: First, it offers up some practice targets that it would like the T-cells to latch onto. If the cells don't bite, they're killed off. The survivors are then released to the second test area. The thymus again offers up targets, but there's a catch: this time the targets are actually pieces of good structures from within the body. If the T-cells go for these, then they are showing autoimmune capabilities and are also killed. This way only the cells that reliably target antigens are allowed to patrol the body. Elegant huh?
I could not for the life of me find a good diagram of this process, so I whipped this up for you: