One Year Anniversary

Well, the Swendiman Family traditions remain intact for one more year, although some have been modified as the years go on. Shelley and I still wake up early, jump on Mom and Dad's bed, and open our stockings. Now though, 9 AM is plenty early. Today, Shelley had to wake me up, and after finding the 'rents puttering around the kitchen, we sent them back to bed so they could pretend to slumber. Then, we burst into their bedroom screaming "Merry Christmas!" and the annual festivities commenced (Mom and Dad even acted surprised as convention dictates). Gone are the days of popping out of bed at seven, anxiously fidgeting by the tree waiting for our 8 AM start time (in those days, we genuinely did have to wake up Mom and Dad, no pretendsies). Now we can't start until we have all have coffee, from Starbucks of course. We go through our stockings, and after more coffee and quick showers all around, we head to the Christmas tree to see if Santa came. This year Santa arrived a bit early: sometime around five in the afternoon of Chrstimas Eve. (The excuse Santa gave was that the weather conditions were looking dicey, and this was a precaution. Also, Santa was tired this year and didn't want to stay up late.). Christmas pictures by the tree and then breakfast. The only omission in our December 25th traditions was visiting Grammy's house after lunch, but I know she is still with us this and every year.

It was a Christmas to remember, and a true joy to be with the fam again this year. I know it may not be long until December 25th is a work day for me. Unfortunately, people still get sick on Christmas day.

There are certain events in our lives that we remember distinctly. Everyone old enough remembers where they were when JFK was assassinated or when we put a man on the moon. I remember 9/11 like it was yesterday. I walked into 2nd period Religion with Father Eck, and the television was on in the east corner of the room. I watched in disbelief as the second plane crashed into the Twin Towers. I remember where I was when I heard I received a scholarship to UNC. It was Friday after swim practice senior year. I heard my Mom's message on my cell phone at the corner of Connecticut and Veirs Mill heading south (right lane, second in line at the light). And of course, I remember where I was (a year ago tomorrow!) when I first got my first acceptance to medical school. I was standing in my kitchen in Finley Forest, holding aloft that sheet of gold from Emory. I grew a couple inches as I read the letter, the weight falling off my shoulders.

A lot has changed in this past year. I've been an EMT, a barista, a world traveller, a pre-med, and now finally in medical school. As a student, I've passed Biochemistry and Anatomy, recorded a rap song about an upper extremity nerve plexus, started the brand new "Health Policy Interest Group" at UNC, and gotten over 1500 on the Helicopter game. But it has been a challenge, in different ways than I expected. Some people I've met have been inspiring, others disillusioning. I've met professors and physicians who are role models, and others who, in my mind, define what not to be as a future doctor. I've spent weeks not opening a book, and weeks where books were never closed. I've laughed, cried, work tirelessly, complained, achieved, failed, rinsed and repeated.

Finally, having a week off being truly free has given me some time to reflect. Having zero responsibilities is a fantastic feeling. It's given me time to smell the roses. When I visited medical schools last year, I observed students coming together and learning in groups, working with physicians in classrooms developing differentials for (made-up) cases. I even got the opportunity to participate in a few of those. I walked through hospitals and watched students interview pateints. On the tours I hearded beepers go off and doctors fly out of the room. These visions made me so ready for third year and beyond, that I forgot about the first two. I haven't stepped in the hospital yet, and the real patients in the clinic I've seen have had either running noses or the flu. I had built up medical school so much in my mind that my dreams could have only been let down. Time off has reminded me, hey, you gotta learn something first, Robby. I think the old addage "See One, Do One, Teach One" was wrong... you have to "Learn One" too. This is something I have vowed to keep in my mind as the year continues.

So I look forward to next semester. Block 3 begins with Physiology (now that I learned what everything is, what the heck does it do?) and Histology (upclose pictures that look like a creative kindergartener drew them - and then we pretend to call it a specific tissue). So let's get it on 2010, and I'm ready to make my New Year's resolutions next week.

Merry Christmas to all, and to all a good night!

One-Eighth MD

So at first I thought I had the "sleeping virus." No, that's not an actual disease, but if eventually it turns out to be real, I certainly won't be the first med student to have ever contracted it. The need for extra rest has gone on for about 10 days, maybe 2 weeks. This week especially; I slept in almost every day. I went to bed around 11 or midnight, and woke up at 9 am. Every day I went through my routine exhausted, and no amount of coffee could wake me up (in fact, it only made it harder to fall asleep later). I ruled out mono and swine flu since I've checked both of those off in college and this past fall, so what's the diagnosis, doctor?

Even though I've been sleeping 9-10 hours a night, it hasn't been good sleep. I wake up every hour or couple hours. But I'm not dreaming about relaxing on warm sand and feeling the cool breeze on a beach in the Caribbean. No, I'm waking up to thoughts of: "facial nerve cranial nerve seven pterygopalatine gland" or "buccinator mastoid stylo foramen alveolar confluence." Usually none of it makes sense. But now I dream anatomy, think anatomy, and wake up to anatomy. There's a pop song on the radio about how some girl is the last thing the singer thinks about at night when he goes to bed, and she's first thing he remembers in the morning. That's my relationship with cranial nerves and head and neck ontology. I think about anatomy all day and then again all night. So I've come up with the following diagnosis: I have "Tortuous Information Requires (too much) Energy Disease," also known by the acronym "TIRED." I am tired, and therefore I need Christmas Break.

It's been a long semester, and much has changed. We have been talking about this change in our Medicine in Society class. Since the middle of August, our family, friends, and even people we've never met, now view us differently. To most parents, we are no longer a son or daughter. We are their sons and daughters in medical school. And there's a difference. Since I've started school, the number of people who have sought my medical opinion has sky-rocketed. I've received texts and emails asking how to determine if someone has swine flu, whether a friend should go to a doctor, how a gun shot to the back can cause blindness, and "Do you think my hand is broken?" My two patients, whom I see through this class (Mr. and Mrs. Jones - Oct. 2nd post), even asked for my advice on how to talk to their physicians, and whether they should be more persistent about requesting more tests. A lot of the questions I get I wouldn't even direct to a resident, much less a 1st year medical student! But as we discussed this with our professor, we found this is par for the course from here on out. From the day we enter medical school until the day we die, we are now part of a different world.

Look at the things we've done. I've disemboweled, mutilated, cut, sawed, and hammered a dead body (illegal in all 50 states). I'm learning how to put in IVs, chest tubes, read radiographs, MRIs, and CTs. Patients tell me the most private information about themselves: their medical histories, their family histories, even their sexual histories. This is just the first four months of school. Imagine what I will have done and what I will learn in the next 7 semesters, and the years to come. It certainly has given me a lot to reflect on over the next two weeks of Christmas break. It is a power that is not to be taken for granted or taken lightly. I'm not a doctor; far, far from it actually. But the past few months have shed light on some of the responsibilities that come with that title. The question is, am I ready for it?

That's why I mean it when I say we are not half way through our first year of medical school. We are "one-eighth MD."

Getting on My (Cranial) Nerves

Next week is our final week of anatomy, and the course directors left the toughest part for last. Right now we are "appreciating" the Head and Neck. Even though this is physically the smallest anatomy in the course, apparently there is a lot of important stuff that goes on up there. I knew that there was the brain and a couple important glands hanging around in the head, but the level of detail is truly incredible, and also slightly stressful. Evolution biting me in the ass once again. In fact, there are 12 cranial nerves that we are committing to memory. Not just memorizing the names, however, we have to know their origin, insertion, what "foramina" (holes) they travel through, what they innervate, and every minute branch. This picture is an example of ONE of the nerves that we need to know. This is "Cranial Nerve VII - the Facial Nerve." Basically I have to imprint 12 of those diagrams into my brain (the actual mechanism of how I am able to "memorize" will be discussed in January).

In order to remember these cranial nerves in order, Wikipedia has supplied us with a number of mnemonics to help us on our journey. Here are a couple of my favorites:

• Oh, Oh, Oh, To Touch A Female Vagina Gives Virgins Amazing Happiness
• O! O! O! There's The Abercrombie and Fitch. Very Gorgeous and Very Adorable! Ha!
• Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly
• OOO Truly There Are Five Very Gorgeous Vixens Awaiting Him

I think you get the picture. This stands for olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, and hypoglossal nerve. Frankly, I think the mnemonic I came up with before I saw all of these wasn't too shabby either:

• Oh, Oh, Oh, Tom Tucker Ate Fried Vegetables Gladly and Vomited Against the House
  

Well, maybe it wasn't that good. But then we have mnemonics for whether these nerves have "sensory" innervation, "motor" innervation, or both (feeling vs. actually moving/doing something). Obviously S = sensory, M = motor, and B = both. Here's what I've got so far:

• Some Say Marry Money, But My Brother Says Big Boobs Matter More.
• Some Say Marry Money, But My Brother Says Big Brains Matter More.
• Small Ships Make Money, But My Brother Says Big Boats Make More.

These are some of the ways you get through medical school tests. By the way, it's that first one in this batch that I've committed to memory. Wikipedia gives such great advice.

The actual dissections have been for lack of a better word, cool. On Tuesday we removed the brain. Literally, we snipped away all the fascia, nerves, and vasculature that connects the brain to the skull, and pulled it out of a human head! In a mad scientist moment, each of us held it in our hands (mostly in disbelief). And it looks exactly like it does in cartoons. All the squiggles (sulci) and creases, they're really there. Pons, medulla oblongata, brainstem, cerebrum, cerebellum... words that come alive right there in your hands. I stood there cupping the squishy organ, staring. It's impossible to appreciate it: the memories, decisions, sensations... this was eighty years of life. Truly the most human part of the anatomy that I have experienced so far. More than the hands, heart, or even the face. It's just another amazing gift that our cadaver has given us...

The big test is next week, and then my first real break in med school. Two weeks back home in DC to read, relax, sleep, and reflect.

Group 4A and Rote Memorization

A couple weeks ago, I wrote about the Anatomy Practical Exam. We walked into the lab with all the bodies laid out in horseshoe around the room. Each had arteries, veins, nerves, or other structures with tiny strings tied around them; or perhaps we found them with a pin piercing through some muscle. We walked around the room silently with a clipboard, writing down the names of these body parts. There was a minute per "question," a total of 40 questions, and 40 loud beeps after time was up at each body.

Yada yada yada. That was nothing. The real fun began today.

This week our practical exam was a group presentation in front of a Professor. Old school European dissection style. Today, we presented the lower limb. There were five compartments: thigh, butt, lower leg, foot, and bones. The four of us (Kiri, Daniel, Eric, and me) pulled out a number from a cup, and we had to point out every single structure in that compartment. I went first, drawing out the number "2" (i.e. the butt, or "gluteal region" is it is more appropriately christened). I had three minutes to spit out all of this gibberish:

"First I want us to remember that we are working within this deep fascia called the fascia lata and you can appreciate the tensor fasciae latae muscle here most superiorly and laterally, then you can obviously see the gluteus maximus, and if you peel that back you see the gluteus medius, the gluteus minimus is just underneath this muscle, and between it and the piriformis you can find the superior gluteal nerves and vessels, putting a finger on the piriformis we can note several very important structures below it and between the super gemellus, most importantly we had the sciatic nerve which turns into the common fibular and tibial nerve as it passes inferior, then the pudendal nerve which passes in and out of the greater and lesser sciatic foramina (and note the sacrotuberous and sacrospinous ligaments, superficial and deep respectively), also we can see the posterior femoral cutaneous nerve and the inferior gluteal nerves and vessels between these two muscles, below the superior gemellus please appreciate the tendon of the obturator internus and then the inferior gemellus muscle below that and of course this flat muscle here is the quadratus femoris, then we need to take a look at the muscles of the hamstring: we have the semimembranosus most medial and then the semitendinosus, and then the biceps femoris with its long and short head, these all make the superior boundries of the popliteal fossa, also remember that these muscles are vascularized by the perforating branches of the deep femoral artery."

A perfect dissection and presentation. Well under 3 minutes. Kiri picked next, and recited the thigh (perfectly). Eric appreciated the foot (perfectly), and Dan got the anterior compartment of the lower leg (perfectly). Then we each grabbed a bone from the leg and presented them to Dr. Gilliland (again perfectly).

"On the foot we need to appreciate calcaneus or "heel" with its calcaneal tuberosity and sustentaculum tali, then see the talus and its trochlea, we have the navicular, the cuboid and the cuboid groove where the fibularis longus tendon passes through, and the 3 cuniforms, metatarsals, and especially note the tuberosity on the 5th metatarsal."

How did we know it so well? Yesterday we all studied individually, then came to the lab at 7pm. From 7 to 9:30pm we drilled and drilled and drilled these dialogues into our head. From there, Dan and Eric and I meandered over the the Health Science Library, where we drilled and recited and read and reviewed what we were going to say over and over and over again. Six pages of material we sat down and memorized, solely for the purpose of spitting it all right back out in the morning. We pointed on each others' legs and feet, and practiced on disarticulated bones. I even dreamed last night of the lower limb. (I'm not joking. I woke up three times last night wondering whether I had mentioned the sural nerve and plantaris - two structures that our body didn't have). And academically, this is the most fun I've had in medical school.

There is no such thing as "quads" or "calves" anymore to me. It's the "quadriceps femoris" and the "gastrocnemius and soleus that combine to inferiorly insert into the calcaneal (Achilles) tendon." Get it straight.

(The picture shows all of Group 4A pulling back an arrow and hitting an imaginary bullseye. That's because we scored a perfect 40/40 on our presentation. Right to left: Kiri Bagley, Eric Golike, Me, and Daniel McMillan.)