Goldiloxycodone and the Three Doses

We just finished the first week of the summer semester, and Pharmacology is dominating the curriculum at the moment. After finishing the day's studying of terms and graphs like these, I couldn't help but act on a moment of creative writing inspiration. Sorry if it doesn't all make sense - you'd probably have to be a medical professional of some sort to get all of it... Enter my parody of Goldilocks and the Three Bears by Robert Southey:

Goldiloxycodone and the Three Doses

By Justin

Goldiloxycodone hobbled as fast as she could away from the three bears’ home, favoring her leg that now had a bleeding bear bite. Her recent attempt at one-upping her cousin’s famous shenanigan was just another in a long line of dismal failures that characterized Goldiloxycodone’s life. Little did she know that she was about embark upon a path that would change her life forever.

Settling down behind an old abandoned shed and sheltering between two metal dumpsters, Goldi broke out the Hello Kitty lunchbox in which she stored her drugs. You see, Goldiloxycodone had gotten into so many altercations with various members of famila Ursidae (who were surprisingly protective of their porridge!) and made enough trips to the ED that she’d developed a bit of a drug problem.

Oxycodone was her vice of choice, playing no small part in her choice of legal self-nomenclature. As she had just scammed the new doc two towns over, her stash was currently fuller than her bleached-blonde curls. Shaking the plastic Easter Eggs she used to disguise her pill hoard (not green... not yellow... BLUE!), she found one that was chock full and began to calculate dosages.

Mental math had always come easily to Goldiloxycodone’s deviously calculating mind, so it was easy as tripping for her to plan out a sustained dosage pattern that would keep her blood plasma concentration in just the right range. Factoring in the metabolic tolerance that she had built up via enzyme induction was no easy feat, but Goldiloxycodone would have been a renowned genius if not for her proclivities toward arson, caustic mocking of others’ answers to bar trivia questions, and overtly expressed desire to become a criminal overlord. Most intellectuals seeking to retain hopes of future publication avoided her like smallpox on the subway.

So Goldiloxycodone ticked off potential drug plans in her brain. No, not number one – that dosage interval is too short; I’d be out of my mind in no time, but with my enzyme count and ripping level of elimination, I’d reach toxicity before I could read the name of my Hispanic-American explorer-child-themed backpack. That dosage plan is too high.

And it can’t be number two – that dosage interval is too long by far. I might get in the therapeutic range, but I want a continuous trip, and I’d be dropping below in between every pill. It’s a balmy night out here, and the IRS just arrested the Big Bad Wolf for some sort of “evasion,” so there’s no reason this can’t last alllll night! Regardless, that dosage plan is to low.

Now let’s see, what about dosage plan number three... This regimen looks adequate, maintaining drug levels in the safe and effective range but never dipping below or reaching toxicity. If I’m careful, I don’t think I’ll even have to break into my purple egg! Goodness, this is turning out to be much less of a disappointment than I thought. Plan number three looks just right!

And so it was that Goldiloxycodone tasted no porridge, slept in no beds, and was never featured in any of Robert Southey’s publications. When she awoke from her stupor five days later with snot crusting her nose and her pinched forearm telling of severe dehydration, she decided that while her math had been spot-on, her judgment was a little impaired as to the definition of “toxicity.” And so, she checked herself into rehab. Six months later, she let her roots grow out, changed her name to Dorothy and moved to Kansas to live with her aunt and uncle on their farm. Sure, there were lots of tornadoes and rumors of “Cardinal Witches,” whatever that meant – but Dorothy longed to make an honest go at wholesome living. As long as there were no monkeys – especially mutant ones. Heavens, how she hated mutant monkeys...

The End

My Foot Has Invisible Issues

Perhaps it's because of all the time spent in third-fifth grade rocking my gym class in kickball, but for some reason my right foot has had it out for me over the last four years.

In 2009, while squatting (wearing sandals for this = bad choice) by my new used car to change the license plate, I shifted my weight and had an unpleasant experience. I remember feeling something pop in my foot, followed by intense pain and swelling. I thought I had just torn something and that it would eventually heal, so I put off going to the doctor. Nearly two months later, after I had been hobbling around on a seriously fat foot the whole time, Wife forced me to see a podiatrist. I did, and I was diagnosed with an evulsion fracture. This is basically where part of your tendon pulls a chunk (a small one, in my case) of bone away from the rest of bone. Mine had occurred right at the base of the big toe on my right foot, on the bottom side. Since the tendon hadn't completely separated, there was nothing to do for it but put it in a big air boot to immobilize it and carry on with life. The most inconvenient thing about it was driving - had to do it with my left foot, since I couldn't flex my right one. Weird.

Anyway, at the same time as the x-ray showed the evulsion fracture, it also showed evidence of gout. GOUT. I remember thinking, "What, have I suddenly skipped five decades of life, that I have gout??" My doctor couldn't explain it either - my diet was fine and everything. I was put on colchicine, and in six weeks (when the boot came off) I was pain-free. I don't know if the injury had anything to do with it or not, but there it was.

So this past December, while walking up the stairs at my wife's sister's and brother-in-law's house (where I had been staying at the time) in the pitch-dark of night, I tripped on some boots/shoes. This wasn't just a trip-and-catch-yourself kind of trip. This was a I-think-I-just-broke-my-cold-toe-off kind of trip. The only part of my foot that caught the edge of the stair was the tip of my right big toe, forcing it back almost flush with the top of my foot as I tumbled forward. It croaked like all the frogs in heaven, lighting up with a fiery pain that took my breath away. Probably the worst sprain I've ever had - located at the area marked by the red square in the above image. It swelled up something fierce the next day, and I could hardly walk. After a few weeks the pain went away until it only hurt when I tried to flex the toe.

And that's how it has stayed for the past SIX MONTHS. If I stub my toe, or try to flex or rotate it, it's a solid 9 on the 1-10 pain scale, and I'm not exaggerating. Otherwise, there's no pain. None when walking, and only a little if you press on the joint. I finally caved and (since I've also built up a weird throat issue and a separate foot issue - topics for another post, another day...) went in to the doctor yesterday, and got x-rays taken today. They gave me a disc of my scans, which for some fool reason was only designed to work with Internet Explorer on a Windows machine, so I had a heck of a time trying to view the images. After some Q-style hackery, I managed to extract these from the interactive software disc (after which I found a real gem: the OsiriX software), saving them as jpegs and uploading so you can have the glorious experience of seeing my foot bones:

Right Foot, Medial View X-Ray

Right Foot, Superior View X-Ray

Right Foot, Superior-Lateral View

Most awkward moment of the image-taking experience: My feet are so big they wouldn't fit on the x-ray plate. That's why a couple of the images above are positioned diagonally; they had to turn the plate to fit my foot and "avoid clipping." Awesome.

Now you're probably wondering, "What do these images show?" That's a great question. As far as I can tell, a fat load of nothing. Granted, we just started our Introduction to Radiology course this week, so while I know a bunch about how x-ray imaging works, I know almost nothing about how to read them. Still, I can't see anything broken, and I don't see any of the cloudy/grainy evidence of gout around the joint that I remember seeing four years ago. They also show no evidence of the other (more transient) pain that I've been having in my foot near the ankle joint.

And so, I'm going to wait for my primary care doctor to review the films, then most likely refer me to a specialist. Ho-hum. At least there's no evidence that I have gout again - though at least that would've been an answer. Probably the worst part about all of this is that the weather is finally nice outside, and I just want to go running! But hey, at least I am still able to walk, and my health in general is intact. In the end, it could be much, much worse.

My Little Backyard Garden

I am currently on a one-week break between the Spring and Summer semesters - almost done with my M1 year. M2, Problem-Based Learning (PBL), and Step 1 are rapidly cresting the horizon, but for now I am quite content to fixate on more quotidian pursuits - like gardening!

With Tiny Wife currently living up her Big Life in Mexico, I decided I would kick-start my small, backyard garden. With my landlord's permission, I started the labor-intensive process of removing the lawn by hand. While you can't see it here, this involved me cutting lines in the grass with the shovel, then sort of "rolling up" the grass, which is a little harder than it sounds...:

 Once the grass was gone, it was time to first hoe, then rake the dirt to make it all soft, removing the larger rocks (and glass and old asphalt and rusty coffee cans) in the process:

 Look at all that fresh earth, ready for planting! I tacked up some chicken wire and got to work getting some starter plants in the ground.

 I have four tomato plants, two poblano pepper plants, one cucumber plant, and four bell pepper plants:

 This area is for seedlings. Currently, I have two rows of carrots and two rows of green beans planted, but I am planning on 2-3 rows of sugar snap peas, per Wife's request:

Other than that, this break has consisted of lots of unpacking of boxes because OH YEAH - we moved, as evidenced by the fact that we now have a backyard for a garden. I've also been doing a lot of sleeping (minus the four-hour night before waking up at 4am to bring Wife to the airport), watching of television (huzzah for guilt-free sloth time!), eating (I love my cast-iron skillet!), and sitting on my porch sipping tea and reading / listening to audio books. Last night I hung out with a couple of friends, and it was a nice break from solitude. So yeah... It is a good break so far.

Retraction

Yesterday I published a post called, "Worst Back Tattoo I've Ever Seen." I am retracting that post because of some feedback that I have received, and I would like to apologize for the post. I didn't think it through, and the below comment from an anonymous user helped me realize that:

"It's kind of insulting that you singled this woman out and felt the need to photograph, mock, and ridicule her like an animal in a zoo. You don't know her story. She could have been in a car accident, or perhaps her family has a long history with the Ford company, that provided her a lifestyle and education to overcome poverty. Or maybe she shares a love for the company that put Detroit on the map that non-Detroiters will never understand. What if she were a patient of yours? Show some decency and reserve your judgment." - Anonymous

This Anonymous is right. I didn't know the story of the woman with the tattoo, and in my incredulity and haste to snap a picture and toss it on the web, I didn't think about how that tattoo could be symbolic of many things. For all I know, Ford motor company created some innovation that allowed her baby to survive an accident in which it would have otherwise passed away. The fact is, it was rude and short-sighted of me to pass judgment on the tattoo and share that judgement on the web. I wouldn't have done that to a patient, so I shouldn't have done it to a stranger.

Thank you very much, Anonymous, for helping keep me accountable - for reminding me that I don't always see the whole of things, and that I should do a better job of realizing this before needing to retract a post. To everyone else - I apologize for the post and the rudeness that it showed. Thanks for reading.

One. More. Test.

This was me ten minutes ago.

It's very rare that I get to say this during med school - One More Test. And it's not really TRULY true even now... Come to think of it, the actual end of my education is so foggy, I'm not sure if there really will be a "last exam..." Shudders and steers mind away from such thoughts.

The end of this semester is almost here! Today I took my last Microbiology exam - this time on Virology - and it went great enough that I indulged myself and took an almost two-hour nap this afternoon. I feel more rested right now than I have in weeks! I can't be a complete slug though - no matter how much I'd like to just play Fun Run and eat chips on the porch for the rest of the day - because Thursday I have One. More. Test.

Thursday's ringer will be Pathology, which has sadly not risen to its potential. You know you're in for a wild time when that day's Path prof (who also happens to be the course director) steps up to the lectern and says (and I'm paraphrasing here), "Well, we sure have been getting some dry lectures lately, haven't we? I'm sorry, but that's not really going to get any better today, as this lecture may be the driest one yet. Just stay with me and we'll get through it."

I think I fell asleep twice during that day.

If you can't tell, I like it when things are just a bit more up-beat... So no, I'm not quite relishing the thought of spending 8-9 hours this afternoon / evening (and ~12 hours tomorrow) memorizing the details and terminology of amyloid bodies, edema, and neoplasia. The plus-side is that I will be rewarding myself with some food this evening for getting through this morning's exam. Not sure where from quite yet, but it's going to happen.

Before I know it, Thursday will have come and gone, and then the next big event on the horizon will be this weekend when Wife FINALLY Moves to Grand Rapids!! We've been waiting for this day for months, and I sort of can't believe it's finally going to happen. All of the plans have been laid, and it's almost here...

After that, I'll have a week of nothing. And I mean nothing but blissful sleep, relaxation, as well as possibly some exercise and/or gardening. That's right - I'm going to start a garden while I actually have enough time to do the digging and planting. We should be past the last frost of the year (*crosses fingers*), and though I haven't had a garden since I was a wee little 'un, I thought this summer might be a fun time to reattach the green thumb that got severed by my education. All right, time to hit the books digital coursepacks!

Locked-In Syndrome

Locked-In Syndrome is officially the most terrifying condition I have learned about so far. In my opinion, it is worse than any form of cancer. It is worse than leprosy. It is worse than flesh-eating bacteria, or Huntington's Chorea, or Broca's Aphasia. It is worse than having all of your limbs surgically amputated. It is worse than being paralyzed from the neck down. Locked-In Syndrome results from strokes to the ventral pons - the shaded region labeled 11 in the diagram above. For clarification, the pons is part of your brainstem - see Region 5 in the midsagittal cross-section below:

When blood supply to the ventral pons is cut off long enough for the cells there to die, you lose all motor function except a select few movements. While there is some variability in severity of conditions, this often means no unassisted breathing, no swallowing, no facial expressions, no eye movements - NOTHING. From what I have read, eye movements are the most commonly retained ability, but even with that, sometimes the only movement retained is of both (in some cases only one) eyelid.

The worst part is that people with this condition can still feel everything. If their eye is dry because they haven't blinked, it will itch and burn like it would for you or me. If they have some saliva trickling down their throat into their lungs, they will feel the need to cough but won't be able to. If they contract pneumonia from not having their lungs get sufficient ventilation (or from never being able to cough up bacteria), the pain and discomfort will be every bit as real and constant for them as it would be for anyone else with pneumonia, but they won't be able to do anything. And unless someone notices that they are able to move their eyelid in a non-random manner and works out a method of communication so that they can speak one excruciatingly slow letter at a time, they will have no way to tell anyone about their pain or discomfort.

It is reading about conditions like this in class (and then searching about real people who have them) that makes me feel horribly ashamed for the minor complaints to which I so regularly give voice. Who am I to complain about feeling tired because I stayed up too late studying, or because I feel sore the day after moving furniture? Sometimes perspective like that which is provided by Locked-In Syndrome is like a slap to the face. I have nothing to complain about, and vast mountains for which I should be eternally grateful. We all do. No matter what our situation is, it can't possibly be as bad as being stuck in a bed, unable to communicate with the world around us, while still feeling like you did the day before - remembering what it is like to move and laugh and talk and hold hands and swim and drive and run and kiss, all the while knowing that you will never do any of that again. Knowing that you will just lie there every day for the rest of your life. Until some bacterial infection gets overlooked, you contract pneumonia and can't fight it off, and you die drowning in your own pulmonary pus. I can't imagine a worse form of torture than that...

So remember - it could almost always be worse. All too often, I think we are afraid of acknowledging what we have - abilities and talents both intellectual and physical - and asking ourselves, "So what am I doing with what I have?" So ask yourself, and be honest:

What am I doing with what I have?

2013 MSU CHM Med Folly - Medical Rhapsody

Great vid by Brittney Benjamin.

Interesting note: I'm in this one... :)
Also: 1:25 features my friend Alex at his finest...

One Year Ago Today

It's crazy to think that one year ago today, I was still working in Human Resources. I knew I was going to med school, but it still felt a long way off. I had just gotten a present in the mail, and all I could think about was starting med school. Time has absolutely flown since then, and at the same time it is very easy to concentrate on exactly how exacting the last two semesters have been.

Right now, we're in the final push of the spring semester. We have a few more classes and a couple exams this week, and then next week just two exams before a week-long break leading up to the six-week summer semester. Today is pretty packed. I've been studying at the med school since 6:00am, though our first lecture is a two-hour required Integrated Clinical Correlation lecture at 10:00am. At 1:00pm I have my hour-long Core Physical Exam assessment, two-hour mentor meeting at 4:00pm, then my final written and practical exams for Medical Spanish Interviewing from 6:00pm - 8:30pm. And then I'll start the evening's studying for the upcoming Neuroscience (Friday), Virology (next Tuesday), and Pathology (next Thursday) final exams.

The nice thing is, these last few exams aren't going to be so bad because we aren't getting new classes throughout this whole time. In med school, and especially this semester, it can feel like one constant exam week that lasts the whole semester, except you're consistently getting new lectures and material that you won't be tested on until the next exam. That's probably the toughest part of first year - the seemingly impossible mountain of exams and lectures that you see on your schedule at the beginning of each semester. I remember looking at February and thinking, "Is this really possible? If so, HOW?" But we got through it, and though it was every bit as difficult as I thought it would be, it was possible.

And now, my first year is almost over. Yes, we still have summer semester, and it won't be like picking dandelions, but we'll get through it. And then comes second year - just one test for each ~1-month-long unit. Talk about "do or die..." We'll see which form of academic assessment I find more/less enjoyable. Something tells me I will enjoy next year a bit more. While I like the finite aspect of first year ("This is exactly what you need to know, and while it's a LOT of information, you know that is EVERYTHING you need to know for this test.") I think I will like the self-guided nature of next year, as well as how everything we learn is based in a clinical case scenario. The concept that we will be responsible for everything in the assigned textbook chapters is a little daunting. First year has been all about learning the information in printed coursepacks, which are basically just condensed textbooks.

All right, enough of distraction in blog form. I'd love to write more, but the thalamic nuclei (and the incessant practice of my core exam) are calling to me...

MSU CHM Medball 2013 and A Med Folly Video

Last night was the 2013 MSU CHM Medball, and it was a blast. The theme was Bond - Dr. Bond, and everything went off without a hitch. The night was the product of weeks of planning by the student council (of which I am a member), as well as many faculty and staff, and would not have been possible without the generosity of MANY donors. For those that don't know, the event is basically a big banquet to celebrate the year, as well as an opportunity to recognize outstanding faculty and staff with awards. Awardees were voted for by the student body, and were presented with special glass Green Apple awards for their contributions and dedication to students.

The night also serves as an opportunity to unwind by hanging out with friends, dancing, and watching the student- and faculty-made Med Folly videos. Once the Grand Rapids vids get posted, you may see your's-truly in a couple of them - but I'll make sure to post each video as it gets uploaded. They do a good job of showing up much fun we can have - even though we're med students, haha. Without further ado, here's one from the East Lansing campus:



Below is a panorama of the ballroom at the Radisson in East Lansing, Michigan. Though you may not be able to tell very much, each table is decked out with all the Bond-themed decorations - wine bottles, posters, playing cards, fake cash, candles, and 007 signs. All told, it was a great night.

UPDATE:
Just after posting this, another med folly was released:

MSU CHM Secchia Center - Awesome View

This photo really doesn't do that sunset justice...

This was my view from the med school last night.

Even amidst all of the flooding that has been happening in Grand Rapids lately,

we sure have been getting some awesome sunsets.

Glad I chose Grand Rapids?

You bet.