Robert A. Swendiman, M_

It's official. I'm halfway through medical school! Well, almost. There's this little thing called the United States Medical Licensing Examination (USMLE) - Step 1, but let's just forget about that for a hot sec. I'm halfway done, which means I could be actually treating YOU in just two years. Isn't that scary? Actually, it should be terrifying. I know nothing. The fact that I can recall the five cofactors involved in metabolic dehydrogenase complex reactions (thiamine pyrophosphate, FAD, NAD, CoA, and lipoic acid) probably wouldn't be that comforting if I were treating you in a medical emergency. This is why for the remaining two years we will be out of the classroom and into the hospital. Speaking of next year, I found out just a week ago that I'll start my tour of Ash-Vegas in Surgery. It has the reputation for being one of the hardest clerkships, so I look forward to getting started. I need a 10 blade, STAT!

Although the past few weeks have been a lot of work, I have to admit it has been (somewhat) rewarding - the ultimate reward will be when I'm in Morocco, obviously. Many times during the first two years, I didn't understand why we were learning what we were learning. It seemed completely irrelevant to medicine. Biochemistry was Medieval torture, an unwelcome extension of undergrad. But, in putting it all together, I've found (some) of it quite useful.

For example, when I had the opportunity to volunteer with EMS, I worked with many wonderful paramedics. I remember all the Trauma 1s and scary calls we received, but recall fewer pure "medical" calls.  However, there were a couple of solid medical scenes I remember clearly. One afternoon we were dispatched to an apartment building for a 2 year old who was "blue." Yes, blue. Pediatric calls are always more intense, because the stakes are that much higher with kids. Emotions and tempers run high, and the parents are understandably shaken. Kids just aren't supposed to get sick. Well, this toddler was blue, and the dad was hysterical. Our lead medic (we'll call him "Todd") looked at the kid, looked back at Pops, and said, "We're going to bend him in half."

"What???" was the father's question, and I was thinking the exact same thing. "We're going to bend him in half. He's blue because he's not getting enough oxygen to his body. By folding he's knees to his chest, we can fix that and he'll pink right up." And that's what happened. Todd cradled the kid in his arms, and bent him in half. It was magic; our two year old was no longer cyanotic.

What I found out later was our patient had a congenital heart condition called "tetralogy of fallot" (TOF). TOF is actually relatively common. It is usually defined by four heart defects: pulmonic stenosis, overriding aorta, a ventricular septal defect, and subsequent right ventricular hypertrophy. In plain English, our toddler essentially had a "hole" that connected the right and left sides of his heart. This hole was not supposed to be there. In a normal heart, blood that isn't carrying oxygen flows from the right side of the heart (through the pulmonary artery) to the lungs to get oxygen. It then returns to the left side of the heart. There, the blood is pumped to the rest of the body to drop off the oxygen and make our muscles and organs work properly. The blood then comes back to the right heart "oxygen-depleted," and the cycle starts all over again. Unfortunately, the hole in this patient's heart allowed some of the blood without oxygen from the right side to bypass the lungs and go straight into the left side! This was made worse because his pulmonary artery (the one that takes blood from the right heart to the lungs) was smaller than normal and tougher to get through. Thus, "deoxygenated" blood was moved to the left side, and pumped to the rest of the body. Well that's no good.

So how do you fix that? You bend him in half! By bringing your knees to your chest, you can increase the "systemic vascular resistance," especially in the femoral arteries (the big blood vessels that supply your legs). This puts a lot of pressure on the blood coming out of the heart, making it harder to pump. In our little kiddo, this pressure was great enough that it transmitted all the way back to the left heart, and pushed blood from the left heart back into the right heart. That forced the blood through the pulmonary artery and into the lungs, allowing the blood to get oxygen! It's a neat concept.

I probably butchered that explanation, but at least I now understand the science behind "bending him in half." It actually stems from an anterior misaligned aorticopulmonary septum during embryogenesis. The embryology connects to the pathophysiology, which connects to the treatment: squatting, or bring one's knees to one's chest (of course, that's not the definitive treatment, but it's a quick, temporary fix). And in a split second, that's what was going through Todd's mind... blue baby - TOF - knees to the chest.

Whew.

I think the next two years are about further developing the knowledge we've already received, and bringing it into the clinical setting (that, plus cramming in about a thousand times more things into our noggins). It's taking the 3 Cs of the measles, and being able to recognize them during an office visit. Science to clinic to treatment. That's what makes a doctor.

But, until then, I'll settle for: "Robert A. Swendiman, M_"

(Only two more years until there's a "D"!)