Med School Tomfoolery - "5 Star Nerve"

In an effort to lighten the medical school gloom and doom, I decided to write a "medical school rap." Yesterday while learning the brachial plexus, a complex bundle of nerves that split and merge and divide and rejoin multiple times in the shoulder and upper arm, I put together a little breakdown of each nerve and what it does. My glorificaiton of the brachial plexus is dubbed "5 Star Nerve," a parody of Yo Gotti's "5 Star Bitch." Go ahead and download the song if you'd like to follow along (you can also find it on YouTube), or just read it as a simple poem. One of my fellow first-years (Ronnie Milam) and I will lay down this track on mp3, hopefully sometime next week. There probably won't be a music video parody on YouTube for this one unfortunately, but no worries! The next rap remix we do (for next year's incoming class - Orientation 2010) will be video taped, edited, and special effected for your viewing pleasure. Until then you'll just have to do with this one. I'll post a link to our version on the song once it's recorded. DJ MS1 aka the White Lightning is back...


[Intro]
Yeeeeeah, yo I’m looking for a 5 star nerve you know, I’m talking about something I can break down for you real simple like, something like this…

[Chorus]
If you got that C-5,
In the arm and its high,
Innervatin up and down,
Plus other muscles on the side,
Then that’s a 5 star nerve,
Yeah it’s a 5 star nerve,
I need a 5 star nerve,
See this 5 star nerve…

[Verse 1]
Yo you gotta start with them roots, C-5 to T-1,
And you’ll end up with the branches when it’s all said and done,
Man it sounds really tough, why learn the brachial plexus?
So if you’re at the beach, spittin game, then you know the nerve to flex it!
So after these roots combine into three little chunks,
You got the superior, and the middle, and inferior trunks,
C-5 and 6 merged, so do T-1 and C-8,
But C7 stayed alone, not gonna to help them innervate,
Now the trunks split up, making 6 small divisions,
3 on the top and 3 more in the posterior positions.
The 2 anteriors all combine, and all the posteriors do too,
As they run down your arm, you can feel em coursin through you (YOU!)

[Chorus 2x]

[Verse 2]
We done roots, trunks, divisions, now we onto them cords,
Keep payin close attention, cuz you’ll find this on the Boards,
Look for the lateral on the outside, and the medial on the in,
The posterior’s in the back, and if you see it with a pin,
Then the axillary artery must be sitting in betweens,
Holdin on them cords like some Skinny tight jeans.
All three cords split in 2, then they branch into five,
Its musculocutaneous nerve that makes your upper arm thrive,
the axillary nerve hits the delts and teres minor,
while the radial helps extend your arms like a recliner,
Median gets forearm flexors and the muscles of the thumb,
And the intrinsic hand connects with C-8 and T-1 (ULNER!)

[Chorus 2x]

[Verse 3]
Now that’s the basic structure, but there’s more branching on the side,
Let’s start back at the top, and down the plexus we’ll slide,
Our first little break comes off the C-5 root,
The levator and the rhoms get that dorsal scap chute,
Then the long thoracic nerve roots from C-5, 6, and 7,
Breathing life in front serratus like the Spirit from Heaven,
The suprascapular nerve comes off the superior trunk,
and walks it out on both spinati like my boy DJ Unk,
The thoracodorsal nerve comes off the posterior cord,
So my lats extend my arms to 10 and 2 on my Ford,
Medial and lateral pectoral, you know what they serve,
And that’s five star rap, about some five star nerves!

[Chorus 3x]

[Outro]
Annnnnnnnd done.

The First Day of School... Again. (No, For Real This Time)

I swear to you, Monday was the first day of medical school. Maybe not really, but everything I dreamed medical school would be began this week. We delved into bodies, discussed real medical cases like House and his team, put on scrubs and wore rubber gloves, and got used to the smell of formaldehyde. Our first lecture was about the history of human dissection and the advancements of medicine through understanding the human form. We learned about embryology and the origin of life, as well as the anatomy of the back. After lunch we took our first steps into the anatomy lab to see our cadaver. On Tuesday, we cut.

During the lectures, I didn't think about what I was about to do. Not until I crossed the threshold into the lab did it hit me, literally. The wafting odor of formaldehyde and embalming fluid was my wake-up call. I'm going to actually cut into a human body! Someone who was alive, who was breathing and walking and talking not too long ago. A real person... As you walk through the double doors into the room, 20 blue cadaver bags lie in front of you, each entombing a different person with a different story. It's a sobering thought. All the hours I spent in the OR with living, sedated people were inadequate. There, I was working with surgeons to make someone whole or better: remove a tumor, gallbladder, or give someone a chance to walk again with a new knee. In anatomy, each person is going to be made unwhole: we will see every nerve, vessel, bone, and muscle. We will cut off skin, legs, and even make incisions through this person's face, skull, and brain. We will barely be able to piece the body back together by Thanksgiving. And yet this is the ultimate sacrifice given to the medical student. It is the only way to truly understand the human form.

Most groups give a name to their cadaver. We haven't yet, in part because we did not look at his face until today (yes "he" is a very elderly man). Some people took the towels covering the face off immediately on Monday, I'm not sure why. For us, not seeing the face made what we were doing more okay or less dirty, or perhaps we were just ashamed. I'm not sure. It's easier to cut into someone's chest wall if he isn’t staring right at you. If he can't see us, he doesn't know who's doing this to him. And we don't know who we're doing this to. But once I saw the face today, I was honestly on edge. Suddenly this body that we've been bluntly and shamelessly carving into for the past week was no longer a body, he was a person again, at least for me. Some medical schools wrap the face and hands until they are part of the dissection. The hands I don't have a problem with seeing, but the face... Whose husband was this? Whose father? Whose grandfather? Whose son??

We went too slow on the first day. We were too careful. Daniel M. and I made the first cuts. We had to turn the body over so it was lying in the prone position, and we cut across the back, all the way from the coccyx to the base of the skull, starting in the middle, moving in opposite directions. With no idea how deep to go, we barely broke the dermis on our first attempt. We were timid. We then made perpendicular incisions all the way to the sides, and peeled layers of skin, fat, and fascia back over the table. He was now exposed, and there was no turning back. Our hands were probing muscles and tissues that most people never see, that he himself never saw...

It was truly an honor. I only hope I can be so generous with my body.

Fart Noises and Gobbling Like a Turkey

Look to the left. This is what I’ve learned to do this past week: make little children giggle. The first patient I saw by myself saw me walk into the room, and ran screaming into his mother's arms. He was not happy at all to see me (I think it was the stethoscope and tie), but fortunately with a few high fives and a chance to let him look into my big ears to see if he could find my brain, he did let me listen to his heart and lungs. After this near disaster, I felt I needed to come up with a few new techniques to gain the trust of my little ones. The first technique I stumbled upon completely by accident. My second case was a two year old girl with MRSA. I had to put on gloves to examine her abscess, but there were only mediums in the room. So during my struggle to get the first too-small glove over my hand, I blew into it to help maneuver my hand into the individual fingers. I looked down, and my little two year old was beaming. Of course, there was only one possible course of action. I blew up the other glove all the way, held it on top of my head, and gobbled like a turkey. When I released the air, it made a fart noise and blew around the room. It was an instant hit with her and Grandma, both. "Dr. Robby likes to play!" Not a doctor yet, Grammy.

There are other things I learned this week. I now know how to make airplanes and helicopters out of tongue depressors. I can push a child's "starter button" (navel) to turn her on and off. I can look through a little boy's ear and see out the other side. I can turn an otoscope on and off simply by snapping my fingers, and I'm even working on my bird calls just in case I find any species of the avian variety flying around inside a four year old's eardrum.

On the other hand, I haven't learned much medicine. In fact, it was frustrating to realize how much I don't know, and need to know. I seemed to have found the one place in America where all the metabolic syndromes and hereditary disorders we learned in Molecules to Cells were discovered. I saw two babies with "floppy baby syndrome," a newborn with a heredity immunodeficiency disorder, a woman with tuberous sclerosis, and a patient who came in with pyruvate carboxylase deficiency which only occurs in 1 in 250,000 births worldwide! I realized that I learned much more than I thought in the first couple months, but I wish I had studied harder. It would have been nice to remember some of the details of these disorders that seemed so mundane and dry in class, but came to life (literally) here in Boone. My preceptor commiserated with my frustration, adding that it will all come with time and experience. I did get lucky with a phenomenal proctor. We spent from 8 AM to 7 or 8 PM in the clinic everyday, with patients waiting for hours and hours. But no one seemed to complain. They all came a long way to see my doctor specifically, and every patient and family member left with a smile (unless they left immediately after their immunizations; then you could hear them leave...).

I have also been surprised to discover I have picked up a significant Southern drawl when talking to patients. At least 90% of the people in the clinic have strong Western North Carolina/Appalachian accents, and quite of few of them are on Medicaid. As the conversations develop, my neutral half DC, half NC accent loses the DC part. Words become longer, and I don't think I've ever used "y'all" so many times in my entire life. I promised myself in high school that I would never succumb to using that ridiculous non-word, but Shelley will be proud of me. I guess that's what I get for living in the South for the past five years. Hey, I'd combine a few more words if I could stay away from city traffic for another few years.

Other tips and observations:

1. Get your kids vaccinated. It's not cool when you come to the office with meningitis. Vaccines are safe. There is no evidence they cause autism. None.

2. Use the European method of potty training. Look it up. The American way is crap (or at least you'll get more of it in diapers and less of it in the actual toilet).

3. Clear lung sounds with a nasty cough and fever means the flu. If I hear crackles in the backles, it’s something else. Don't ask me what though.

4. Nobody under thirteen years old actually likes shots, so let them get the flu-mist. It's better and they won't hate you for at least a day.

5. New mothers and fathers who write down their questions in a little book ahead of time are adorable.

Anyways, back to the classroom on Monday, but at least it's Anatomy. Time to cut. First though I'm heading down to Troutman, NC to spend a day or two on the lake with Brandon and some med school peeps.

Farewell, Molecules to Cells

Farewell, Molecules to Cells. I will not miss thee.

On Wednesday I took my final exam in biochemistry (and passed!). I have moved on emotionally, physically, and spiritually from (hopefully) the most boring topic in all of medical school. Frankly, I don't think anything can be more off-putting than RNA polymerase II (see left) and its transcription factors. After talking to some of the MS2s, apparently this is the worst block of our first year, and luckily we start Anatomy in just over a week. But first off to Boone, North Carolina for my first Community Week. Finally back to seeing real patients and human interaction instead of tyrosine kinase receptor / hormone interaction...

It was a fairly tumultuous week, beginning with the annual MS1/MS2 keg race. This past Saturday at 10 AM the kegs started flowing. 20 v. 20. Why we had to start so early I'm not sure (I guess a 9 AM wake-up is sleeping in for med students?), but the experience took me back to undergrad. We won (of course), but I think the best part about the morning was getting yelled at for drinking too slowly, being too social, and not being enough of a team player in my efforts. Apparently med students are like athletes: we like to win (or at least get an "A"). That even includes our "extra-curricular activities."

That time could have been better spent studying, however, duty called. Sunday through Tuesday was spent in the library gearing up for our final, and it was a relief to be free at noon. Ginny Moye and I then drove up to Blowing Rock, NC (right outside Boone) to spend some time at a mountain time-share that one of our classmates had for the weekend. About 20 of us made it up there, and we spend the time going for walks, seeing the bears, cougars, and bald eagles (all in captivity of course), "climbing" grandfather mountain, and debating whether Lawrence v. Texas negates the North Carolina anti-sodomy statute (this one is still up in the air; if you are an expert in NC Criminal Law please contact me immediately). This gave me the opportunity to really meet some of my fellow students. I met an MS2 named Shane who summited Kilimanjaro just a day before I did this past July. And one of my classmates, Ronnie Millingham, lives a block from Brandon Suddreth's house, and was in the same EMT-I class with me this Spring. Small world.

I recently posted on my Facebook status that I couldn't wait to start "real" medical school next week. I have a week of shadowing starting Monday, and then Anatomy begins 7 days later. I thought I would be nervous to start dissection, but I think I was so disillusioned by Molecules to Cells that I'm just plain excited. I see the relevance in this Block (obviously), and when you think about medical school, this is what comes to mind. Dead bodies, scalpels, tissue, cutting. I just can't wait to use my hands. And after reading Christine Montross' Body of Work, I'm very interested to see how I respond to the tense emotions and stresses of the Anatomy Lab, the real bodies, and my classmates. I think I have a good group of students I'm working with, but people deal with all this in many different ways. I certainly view the body with a ton of reverence after reading that book, and I hope my fellow group members do the same.

It looks like I have a good couple weeks ahead of me. Hopefully I won't make a little kid cry. I might not be able to post until Saturday if I don't have internet, but I should be able to write by Friday night and share some of my community week experiences.

What It's All About

Last week's frustration was mollified by the high emotions of the past few days. This picture of Pops and me outside the Old Well was taken immediately following our White Coat Ceremony. In the early 90s, medical schools started conducting these events to give the students a "modified" version of the white coat (not a "long coat" so we can be designated as the scrubs, lowest on the totem pole), to be worn during any clinical experience. For us, this comes just before our first "Community Week," where we spend 5 days shadowing a physician in some other part of North Carolina. On October 12th, I will be heading to Boone to shadow a pediatrician at his practice. Throughout our first two years, I will go back to Boone 4 more times, building on each with the clinical skills I learn in Introduction to Clinical Medicine (ICM). In this first week, I will mainly be a shadow, but will be able to conduct some patient interviews. By the second week I will be performing full physical exams.

The actual ceremony took place on a rainy Saturday morning. We all dressed up in our Sunday best and processed into the great Memorial Hall into the beaming smiles and gleaming (though sometimes watery) eyes of parents, loved ones, and faculty. They gave us a speech about giving money to the school (typical), not cheating (just plain odd), and about being caring doctors (trite), but it all seemed to mesh into nervous enthusiasm from the 160 of us. We were "coated," recited a modified version of the Hippocratic Oath, and processed out to the Tar Heel Fight Song for pictures. The Carolina grads walked briskly over the Old Well to get in line for some classic shots. Lauriane (Mercer '06) had to ask why we were going to take pictures next to "that column thing." They'll learn soon enough, but it gave Pops and me a laugh, taking us back to Searching for Bobby Fischer. Old school.

On Wednesday I went to see my first patient. In our Medicine and Society class, we have to meet with a pre-selected patient from UNC-Hospitals twice to learn first-hand about disease; it also gives them a chance to tell us how we should be good doctors, from the point of view of the person who is actually getting the treatment. Most medical students have never been ill (a point I argued two blogs ago), and this experience allows us to "get real" about disease. I can already tell you that I will not be seeing Mrs. Jones (a pseudonym) just one more time. I intend to be involved in her care, hopefully for years to come. She is an inspiration to anyone and everyone; and her outlook on life, disease, and death is unparalleled. Although I will tell you a little bit about her, for patient confidentiality I will have to change names and a few of the closer details.

Mrs. Jones and her husband are in their 80s. She's had a number of cancers, been through a dozen chemotherapy treatments, been poked and prodded by too many doctors here at UNC and Duke... but you could never tell. She is joyful, thankful, and bubbly. She is a full time volunteer, wife, great-grandmother, and child of Christ. She has lost her hair a number of times, but never her dignity. She is real about death and disease; she knows her time will come soon. She even joked that whoever "goes first" (her or her husband), the spouse will buy two dogs to keep them rolling. Doctors have made mistakes in her care, but she has never been angry. "Everyone is human; everyone makes mistakes." Her best advice was to listen, really listen to patients, because they know their bodies better than you do. We talked for over three hours, and I can't wait to go back. Being with her and her husband reminded me of Grammy, and how much I miss her perspective, wisdom, and guidance. It also was a serious reminder of why I want to be a doctor, and how I should go about it.

Many emotions and ideals this week: pride, joy, love, realism, sadness, inspiration. All good reminders about what it's all about.