Ode to Neuroanatomy II

Damn you Neuroanatomy, you've come back to haunt me!
With your cross-sections and nuclei, you eagerly taunt me.
You want me to remember it all? That's absolutely redunkulous,
Even something as simple as the motor homunculus.
But nay! I must recall the pathways for somatosenation,
And lesions of the paramedian pontine ridiculous formation.
Then you add pathology (ugh!), now I'm filled with nostalgia,
For a Block that's far less painful than trigeminal neralgia.

First year was simple, just little axons and gliosis,
But now studying this path gives me hyperhidrosis,
This year it's ptosis, psychosis, and the nucleus pulposus,
Plus all the co-morbidities of tuberous sclerosis:
Okay, you've got seizures, ash spots, and angiomyolipomas,
Shagreen patches, hamartomas, and rhabdomyomas.
But this is just the beginning of the tumors and "-omas",
There's the meningioma, schwannomas, and medulloblastomas!

Wait! I failed to mention the pilocytic astrocytoma!
And its nasty adult partner, the grade IV glioblastoma.
These diseases are no joke, it's all serious business,
That's why when I'm wrong on a question I get hemiballismus,
Not because I've lost the ability to inhibit my thalamus,
Nothing's wrong with the stimulation of my trusty G pallidus,
If I'm wrong I throw a tantrum, develop chorea, and flail,
Because I know I must study even more! Else I'll surely fail.

But if I fail I'll defend my ego with conscious suppression,
And turn back the clock like maturational regression,
Forget med school, I'll drop out! See what else is in store,
Maybe make like an oligodendrocyte and turn into a whore,
Myelinate dozens axons and forget all of my scruples,
Although I'd rather not end up with Argyll-Robertson pupils.
That work would be easier, I could get help from Cialis,
But it's these kind of thoughts that get you tabes dorsalis.

Now it's one year later, and I still can't pay attention in class,
My right hemisphere has failed me (again!), there's no way I will pass.

(in case you missed the original from last year, check out Ode to Neuroanatomy)

God's Autopsy

As a part of our Clinical Medicine Cases course, each of us is required to observe an autopsy. It's been a solid year-plus since I've delved inside the human body, but upon entering the medical examiner's office I had the same sense of anticipation I felt as a first year. I can't pinpoint the exact reason for this returning feeling, but there is a tangible sense of violation of human form that evokes a reaction on the fringe of my consciousness. I'm not appalled, it's not sickening, and I know it's not wrong. For some reason though, entering the body of the dead just isn't right either. In front of me was (is?) a person. Just laying there. And over the next hour or so, that person will become unrecognizable, pieces of her former self. Heart, brain, gut, lungs will all be weighed, measured, sliced, and cut into pieces to be examined grossly and under the microscope. The skin over the face will be peeled back, and only the legs and arms will be left intact. A human being is now sitting in jars of formaldehyde. What is left is splayed on a cold, metallic table. A soul is gone; clinical science has taken over.

Kelly Esposito, Stephen Vance, Eric Golike, and I were presented with a 280 lbs. 31 year old female. She was approximately 5'6'' with no external deformities or obvious causes of death. It was surreal to see someone so young rest limp and lifeless. But there was no time to delve into questions of the soul or God. A differential diagnosis was to be formed. After changing into scrubs, gowning, gloving, and shoe-/eye-protecting, the four of us assembled in a semi-circle before the attending. I proffered the possibility that drugs were the etiology of death. Seeing our patient (person? specimen? patient? yes, patient) laying there on her back reminded me of my first overdose call working EMS. A woman in her upper-30s was found on the floor of her bedroom by her 10 year old son. The firefighters had begun CPR when we arrived, but the paramedic I was working with called it off immediately  Blood had pooled to the posterior trunk and legs. It was my first clinical experience with death.

Turns out this picture was similar.  Our patient had overdosed on pain-killers, fully depressing her respiratory drive to the point of asphyxiation. Apparently this is a relatively common occurrence in the medical examiner (ME) domain.  Someone so young makes one reflect on one's own mortality  Yet again, there would be time to reflect later. In less than an hour the ME, nurses, and fourth year medical student dissected the body; it had only taken us eight weeks in anatomy. Just like in the movies, a Y-shaped incision was cut into the anterior chest.  Unlike in the movies, the ME didn't use a scalpel. Instead, a kitchen knife of the CUTCO variety was the instrument of choice. Within the first few minutes, the heart, lungs, and gut were removed, washed, examined, weighed, cut, chopped, felt, excised, placed in formaldehyde, and sent off to the pathology lab. The liver was chopped into slices like a piece of meat (I won't name any meats specifically so dinner is not ruined).  The heart was examined in sections to evaluate the patency of coronary and major vessels. Even the tongue and oral cavity were excised to look for obvious signs of choking and/or bruising. In a moment of lucidity (or "awakening" from my clinical state), I remember thinking, "Damn, this man is holding a person's tongue and trachea in his hand!  WTF?!" But again, I had to snap back into my desensitized state.

In retrospect, what snapped me back was most likely the smell. It was unlike the comfortable formaldehyde aroma of the anatomy lab. Thank Jesus for the windows in that building. Even though none of them were open, they at least allowed my eyes some escape, but by the end of the hour the fetid odor was the status quo.

If the smell didn't get me back in clinical form, my anatomy-recall deficiency (ARD) did. While our attending held the tongue/former breathing apparatus, he quizzed us briefly on the anatomical structures. Fortunately Kelly saved us with her AR thyroid knowledge. This ARD reminded me that I definitely should do some sort of anatomy rotation in my fourth year; it seems "high yield" for the rest of my life. A number of fourth years, preparing for their general surgery residency, spend a couple of weeks under the medical examiner's tutelage to refresh their anatomical acumen (e.g. our fourth year assistant). Come to think of it, I wouldn't mind doing a radiology rotation for this same purpose.

As far as learning goes, our patient had pristine anatomy despite her death and her BMI.  Her aorta had minimal fatty streaks (the beginning of atherosclerosis that can be seen even in teenagers these days) and her heart lacked hypertrophy.Yet there she lay. Dead. In most cases, one hears the patient's story, but our lady had nothing to say. Before they cut into her face and scalp, I wondered what would she have told us. Was she depressed or angry? Who hurt her? Was this her first and only attempt? Had no one heard her call for help? Did anyone care?  Did she have children? A partner? Who found her? I hoped it wasn't her children. It is unfathomable, even after seeing it happen in real-life while working on the ambulance: You're a fourth grader getting off the bus after school, walking across the street to your house, up the stairs, and there is your mother on the floor, a bottle of pills beside her, half of them gone, she's cold and lifeless, she doesn't respond to your call.  Mom?? Wake up.  WAKE UP!  You run to the phone and dial 911, police officers, EMS, firefighters, dozens of people in your house, they tell you your mother is dead. You are too young to comprehend your own mortality.

I guess now is the time to reflect, and yet I don't want to. They say there are two types of medical students: those that think they have every disease, and those that deny their own morbidity and mortality. Before, I have thought I was in the former category, but it is scary to think of everything that could happen to you. One in 1000 get this, 1 in 500 get that. It's amazing that anyone is even born "normal" with all the possible genetic mutations and deletions that could occur in utero. Every disease I see that says it "affects males more than females, more common in people of northern European descent," that could be me. And some of the diseases are truly horrible diseases. What if today I was diagnosed with ALS? What if I had a year left? This woman was 31 years old. Thirty-one! I won't even be out of residency then. I'm not ready. I need more time, but that's not my choice. This, like gross anatomy or the autopsy, also provokes a visceral reaction, one that I'm not ready to confront. And yet it is one that I will confront almost every day as a physician. Will I push it away? Will I become so desensitized to death that I will forget my own mortality?

An autopsy is an investigation. With a short history, a physician examines a dead body to discover the cause of death. In some cases, the diagnosis is simple and straightforward. In others, you need a microscope and tissue samples to narrow down your differential. And many times you never find out why your patient died. In today's culture we separate science and religion. So who does our spiritual autopsy? At the end of the day, who dissects our soul? I don't know, but as we were standing there observing man's final judgment, I couldn't help thinking...

God, are you waiting?


(Note: some details concerning our patient were subtly changed for her privacy.)

The Pitter-Patter of Learning

“The sound.” Everyone has one, a noise that absolutely grates on them and grinds their gears. There’s the classic “fingernails scratching across the chalkboard,” the chink of someone biting their fork whilst eating, or even just the thought of chewing on tinfoil (mentally masticate on that, just awful). Any one of these makes you grit your teeth, but since I’ve started going to class again (surprised? hopefully it will last longer than you think…), I’ve found a new one. It is the reason I started watching lecture capture in the first place actually, but I have been re-reminded of it in 2011. Four or five times each lecture, the professor will say something VERY IMPORTANT. It may be prefaced by the words: “If I were you, I would know…” or “This here is often tested on the Boards…” or “All second year med students should remember…”

And then it begins.

Fjdlksa;jflkdsa;jfkdlsa;jfkdsa;jfdhgiwauroieauwreqpureihgvn.,zhvjoiurwahgd;sahg;oewiqyuierahd;ahvfznbc.,mzhfd;iahfrioufiewpqygirapiewqpgirqhg;rakdvdlka (wait, what did she say??) svndzkvcxz.vnghja;heiqoturiqptirotupwirutuoir;lkav;dsanvdm,z.v,fdahjrkd;aher;ahgirohgirutireqptyirpqtuirepwytrqptirytriqoptphiah;lkdhkd;lsafkdsa;vfndzv,mcxz.nv (deep breath) c,mz.vncxvnda;fjdka;fdksajfkd;sajfa;fjkewriueqtiueqptywqtye (did you catch that?) wtyrittypoyieprqiepwqytoiewqyteptrewipqiewptrewipytiewqutewtryiewoqupoieqtryoiewqhfid;akdajds;adsag;lahg;dancvzxv.,mcxznvc,.xznvxz.nvbdafhew;hfe;fda;klfeoiwtiytreoiuytoitoeqwpureioqrjieq;riewopqytreiqtyriwtyirewqtuirepwqjfd;sajfkds;afdak;lnvczvnc.ncx,mzbv (oh no!) nvcxzm.nvcx,mdfj (gasp!) d;lkafjk;areioqtuprepwquitrpiqiepowqrueqpryeqwtuperwoieruowqptrueipowtroiewq;dafjdk;slavnc,mxznmnbmzn.

Click, click.  Ramsey Wehbe pictured above, caught in the act.

It’s the cacophony of a hundred people on a hundred laptops with a hundred keys. It’s the low murmur of continual soft clicking, a violent war of attrition against A-Z and their sister punctuations, a smear campaign against the quick brown fox who jumped over the lazy dog, a genocide against QWERTY and his friends. It’s the “test-freakout,” “the holy shit this will be on the exam,” “the possible/probable BOARDS! question,” And if it is not typed absolutely immediately into OneNote, the information will be lost forever. OH NO, I MISED IT! BOARDS?? BOARDS?? DID SOMEONE SAY BOARDS???

Sorry for the melodrama, Kelly, but today it is necessary.

I have written about studying for the Boards in multiple blog posts because it is impossible to chronicle my second year experience without it. The teachers talk about it; we study for it. I have been taking it fairly seriously, but I love being obnoxious about it in class. Reactions are priceless. I just can’t stand the incessant typing though, probably because I’m wallowing in my own inability to pay attention. It’s very hard to sit fifty minutes without checking on the Caps playoff prospects, or check Kendall Marshall’s career stats at UNC (and Facebook, of course). I am amazed that people can pay attention for that long in the seated position, and that’s probably why I’m vexed. Dammit, why do I have the attention span of a 13 year old boy who just bought SI: Swimsuit edition?! I guess I just wasn’t made to sit for hours on end, listening to professors wax philosophical in 1.0x speed. If they could just up the vocal speed to around 1.5-1.7x and eliminate the ten minute breaks, then we could be out of there every morning by ten o’clock! And then I could type on my own laptop in peace.

Every once in a while it's fun to throw out a random little bit of knowledge, just to see the cogs turn.  Lean over to the row in front of you and whisper, "so you know Alport syndrome has a defect in type IV collagen, right?"  Then just sit back and watch.  Watch for the quick Wikipedia look up, the nervous retort, or expectant page turns of an open textbook.  It's all in good fun (although it's probably the reason I have no friends now), and I get pranked in return.

So please, just relax; and go easy on the home keys. They are your friends.  Pound on them too hard and soon you will have a space bar enzyme that no longer creates spaces, leaving you with a build up of constants and vowels in the bloodstream of your notes.  Like Lesch-Nyhan syndrome and the accumulation of uric acid in the absence of HGPRT, your incomprehensible notes may lead to choreoathetosis, self-mutilation, and aggression without this "key" enzyme.  Wait, or is that Adenosine deaminase deficiency?  Or Ehlers-Danlos?  Niemann-Pick.  Shit!  I better look it up...

Fdfajk;auireopwqureiwqpyfidfdja;lkfjdsa;lkfjdlksa;jfdlks;ajfkd;lsajfdhauirepqhydisajncmxz,nvcewureipowqajfkd;laruierewfjdksa;fjkd;lsafjkd;sajfdk;sajflkdsa;uiopuipuiopjkrelw;qrueiwqpourfidsapfydpiusaygudsagypiudsaygudpiagiruepoiafyiepoayfewi.  Click, click.

My own pitter-patter of learning.

The Damn Sesamoid Bones

I learned a very important lesson a couple days ago during Community Week #4 in Boone, NC: I am nowhere near ready to be "pimped" on the wards.  Nowhere close.  What does it mean to be "pimped," you say?  UrbanDictionary.com (one of the premiere and most prestigious sites for defining hip new colloquialisms) states that being "pimped" means "to have been used and abused," or in the medical sense, "when an attending/resident/intern asks specific questions about medicine, to the point where the lower rank (usually med student) no longer can answer the question."  Used in a sentence, one could say: "My attending was such a jerkface today, he pimped me for about 30 minutes on kidney disease."  The bottom line is, I don't know squat.

I spent a lot more time with my preceptor this week.  Instead of performing most of the histories and focused physicals myself, I saw most patients with my doc.  We took this approach so that with each patient we could focus on a "clinical pearl," something I could take away as a learning point with each patient.  For example, we saw a little five year old boy with the flu.    He had a very dry cough and there was a red tint to his eyes.  Clinical pearl: almost every patient with the flu has a very unique dry cough; if you aren't coughing, you don't have the flu.  Patients also may present with eyes that can be red or bloodshot ("flu eyes").  So with each patient he discussed some clinically relevant tool that I could use moving forward.

I would say that I recognize/understand about 90-95% of what he talks about, but cannot always recall the information directly.  I know that the three most common causes of meningitis in the first three months of life are E. coli, Listeria, and Group B Streptococcus, but if he asked about that information on the spot, I wouldn't be ready to regurgitate it back (however, after working through "Clinical Microbiology Made Ridiculously Simple" this week, I have made much progress in my Microbiology knowledge).  When we're on the wards next year, this is part of the teaching style.  Professors/Attendings will ask us questions to assess our knowledge, and keep asking questions until we're stumped (which probably that won't take long).  I realized over Community Week that I have a long way to go before I seem even remotely intelligent.

Since I've spent the first few Community Weeks in Pediatrics, I was supposed to spend some time in a general medicine clinic for at least a day this week.  The Emergency Room is right next to our AHEC housing, so I decided to take a morning and shadow around in the ER.  The doc I worked with only knew that I was midway through my second year in medical school, so he began asking me questions right off the bat to see where I was in my training.  I was also working with a PA student who was in her last year of school.  She had been working in the ER all week as part of a one month rotation.  The doc threw up an X-ray of a woman's thumb and pointed to a tiny little white spot medial to the thumb that looked like it was hanging in suspension.  He asked me what bone it was, but the blank stare on my face was a dead giveaway for my incompetency (I thought it looked more like an errant calcification than a bone).  The PA student quickly piped in, "I think that's a sesamoid bone!!" (enthusiasm exaggerated).

That's correct, and it looks like someone needs to go back and start flipping through their Netter's flashcards...

So for the first time in my life I was very glad I had a smart phone on me.  I quickly pulled up the entry in Wikipedia for BlackBerry (after figuring out how to spell it correctly), and came up with the following:

In anatomy, a sesamoid bone is a bone embedded within a tendon.  Sesamoids are found in locations where a tendon passes over a joint, such as the hand, knee, and foot. Functionally, they act to protect the tendon and to increase its mechanical effect. The presence of the sesamoid bone holds the tendon slightly farther away from the center of the joint and thus increases its moment arm. Sesamoid bones also prevent the tendon from flattening into the joint as tension increases and therefore also maintain a more consistent moment arm through a variety of possible tendon loads. This differs from menisci, which are made of cartilage and rather act to disperse the weight of the body on joints and reduce friction during movement.

Now at least I didn't feel like an idiot for the next couple hours.  So then I decided that I would be the one who asked the questions.  It was my way of saying, "I know that I don't know anything, but hey, at least I'm interested and ready to learn.  I will be your Padawan learner.  Teach me, Yoda."

And I am interested.  I just have a long way to go before I have a good handle on the force.