Monday, December 30, 2013

Christmas Break Recap

It's been over two weeks of break, I've had hardly anything to do, all the time in the world to do it, and I've hardly posted. Definitely slacked off on the blog...

Sorry.

A little.

You see, I've been living the life. I've actually RELAXED this break - unlike last Christmas break. I've spent time with Wife (who also has completely failed at journaling via blog, though long before I began my fail...), Hobbes (who now weighs a healthy 52.6lbs and is well on his way to a hefty 70-90lbs just like his dad), and various other family members. Break has been amazing.

I've also toured the med school, aeromed program, and emergency medicine residency at Western Michigan University, as well as started to schedule a ride-along in the emergency response service operated by the EM residents there. Big thanks to my little sib at CHM for using his grade-A connections to pull all that off.

Other updates, other updates... Oh! Hobbes had surgery on his right paw to remove a deformed dew claw. Big bummer there, as we had to take a 10-day break from playing. No running, no jumping, and no going outside without a bandage and a big plastic bag driving him crazy. That's all over now though, and his scar has solidified just fine so far - just a little left to heal over.

Christmas with both sets of my parents went great, and Christmas with Wife's family commences tomorrow morning. After that, we're going to see The Secret Life of Walter Mitty, which is supposed to be phenomenal. After THAT, we're going to celebrate the New Year's Eve in total introverted nerdstyle. We're looking at a quiet, relaxing night in with Thai food, bubble tea, other snacks and drinks, movies and games - all night. Can't wait!

I'm hoping to put up a photo post of what's gone on over break in a little bit, but I have my doubts about whether or not it'll happen... Just not sure. Frankly, I'm doing my best to live an unregimented life for as long as I possibly can until I have to go back to every day being thoroughly scheduled out. This semester, we'll all be killing ourselves gearing up for the USMLE Step 1 Licensing Examination, which I've signed up to take in June of 2014. It's a beast - eight hours long, covering everything from the first 2 years of medical school. My school recommends using The Step 1 Method by Dr. Dan Gabremedhin, MD. After reading it and attending a talk by him on the subject, that's what I'll be doing. Actually, I've already (half-heartedly) begun, but I'll be really hitting the practice questions harder starting this week and continuing throughout this semester.

Anyway, sorry for the long hiatus, but it was necessary. I'll be back into posting once I'm doing more stuff on a regular basis. Until then (or until the photo post idea I floated earlier materializes), have a great holiday season and a happy new year!

Sunday, December 8, 2013

What Does The Spleen Do? Video by Harvard

Life is continuing in its crazy trend, as this week is exam week. Clinical Skills went well on Thursday, but Epi and Psych lie in wait on Tuesday and Friday, respectively. Till then, enjoy this parody of The Fox by Ylvis put out by the second-years at Harvard's med school:

What Does The Spleen Do?



Well done, Harvard. Well done.

Thursday, November 21, 2013

Oh Man - Life

Every once in a while with this blog, I get a bit off track. I notice that it's been a while since my last "real" post. And then I notice that it's been a bit longer. And then a lot longer. Then it's been so long and so much has happened that I have no clue what to write about. There's just too much, and to do it justice would take more time than I can devote to writing a blog post.

That's where I am right now.

So, I'm not going to try to get all the details in. I'm going to write a few short sentences about each thing that has happened recently (in addition to the endless studying and class), then just move on. Otherwise, I'll never make it to the mountain of stuff standing between me and midnight whenever-I-get-to-sleep.

October 22nd - I shadowed an emergency physician in the children's hospital downtown. I never knew how much fun or how difficult that could possibly be. My heart tore for some of those parents.

October 22nd - I had the Musculoskeletal Surface Anatomy assessment. Stuck 6 stickers on randomly-selected locations on an actor's body, then explained my choices to a physician. No sweat.

October 23rd - Started the second round (last year was the first) of Epidemiology. Not my favorite.

October 24th - Had a recorded pretend visit with an actor/patient who "had asthma," and had to write a SOAP Note for it. Not a big deal, but it's something I'll want to remember later.

October 28th - Learned about some "alternative medicine," which seemed to be a large pile of hokum. It was a 1.5 hour talk, and it was required. Not all alternative medicine is bunk... but this was.

October 29th - Attended a suturing clinic and learned five different stitching techniques used to sew up wounds and close after surgery. I had a blast and met some ER docs, which was awesome. Can't wait to put this to use next year.

October 29th - Began donating plasma because we were learning about clotting factor administration options for patients with congenital and acquired bleeding disorders, and I wondered where all the plasma comes from. Found out I can study while doing it, and they give you money on a debit card each time. I don't know how it counts as "donating." Still - SCORE. Researched side effects and found out they're so rare as to be nonexistent. Been back twice per week since.

October 31st - Did my first real (with paid volunteer actors, not actual patients, but still) breast exams. A faculty preceptor and another student were there during the whole thing, but it was still the most real-doctor experience I've had yet.

November 1st - Saw Ender's Game in the theater and remembered what it's like to be a human on a Friday night. Hung out with friends who AREN'T in any way related to med school. Read the book first, but don't expect the movie to compare. Still. Awesomeness.

November 5th - Gave fake bad news to an actor that his child had been diagnosed with Type I Diabetes, teaching him about the disorder and offering support to deal with the news. Interesting, but probably would have been more beneficial if I'd gotten one of the tougher "bad news" scenarios, i.e. cancer, Marfan Syndrome, etc.

November 18th - Took the Hematology/Neoplasm 3-hour monster exam. Passed, but not the happiest with my score. Maybe my standards are too high. Maybe not. Regardless, now we're doing the Psych (Disorders of Thought, Emotion, and Behavior) domain. Much less tangible. We'll see.

Today - Attended 3 lectures this morning, then skipped one to take Hobbes to the dog park we just discovered virtually AROUND THE CORNER from out house. It's amazing. He loved it.

Today - Nursing home visit. Spoke with a senior citizen for two hours, learning about all aspects of her history that led to her residing in the home. Afterward presented her case to her attending physician and the group of med students. Took a long time, but it was good practice eliciting patient information and doing elements of the core physical examination. Good experience gaining practice at interacting with a senior citizen, as I've not had much practice at this other than with my own grandparents, all but one of whom have now passed away.

Today - Impulsively went grocery shopping on my way home from the nursing home visit. Wife is in the middle of three 12-hour 7p-7a shifts in four days, and was stressing a bit the other day about how we have no food. None of the food needs any preparation, so we're set for at least the next week. Also grabbed her a bouquet of flowers. Surprised her with everything just as she was on her way out for tonight's shift. She loved it!

Tomorrow - Will shadow an attending ER physician at one of the largest trauma centers in West Michigan. Should be interesting, on a Friday afternoon. Wish the shift was later in the evening so I could see a bit more action, but Wife and I will be having dinner with a couple of friends, so I guess it's okay. :)

Man, even with tiny synopses, that took a while. Time to hit the books.

Saturday, November 16, 2013

Hobbes Learns to Go Down Stairs (a flashback to good times while studying for Heme/Onc)

Wife found this on her camera while I was studying, so I tossed it onto Vimeo. 
So enjoy - and wish me luck this Monday on the 3-hour Hematology / Oncology exam.

Hobbes is a golden retriever puppy. Here, he's just five weeks and six days old. This was the first time he ever went down stairs. We'd never tried to teach him, and he'd never tried it on his own. I still can't believe he got it on the first try.

Minor note: apologies for not posting recently. Life has been insane.

Monday, October 21, 2013

Musculoskeletal Domain - Check.

Aaaand, that was the fastest course ever imagined. Two weeks and OUT. Today we took the Musculoskeletal Domain exam. It was touted by last year's class (well, by a few of the people that I spoke to, anyway) as one of the easier domains of the year. While that might technically have been true in terms of the volume of material, I don't really think it was true of the domain exam. How can I put this... It seemed like this exam, more than any other that we've had so far, tested us on the minutiae of the domain, rather than the key main and important concepts. This resulted in a bigger flurry of post-exam question challenges than I've seen before. Yeah, that's only two domain exams before this, but still. The staff member proctoring the exam review session had to go get more question challenge forms printed off when she ran out after about an hour. Yeah. Lots of questions that tested on tiny sentences from the coursepack, while some others didn't seem very well-written to many students.

And now, it's on to Heme/Neo (Hematology & Neoplasm) - what many other schools refer to as HemeOnc. This is stereotypically the hardest domain of the semester, and at four weeks long, I'm ready to believe it. The exam for this domain is slated at 3.5 hours long. That's a long exam, testing over a huge volume of information.

But enough about that for now. Today, Wife and I took the afternoon off, and it was glorious. We ordered a pizza and spent a few solid hours just chatting, playing with Hobbes, ordering a pizza (and having it delivered!), and watching some TV. We're currently back at it, getting stuff done, but it was a great way to relax after a stressful weekend of studying.

Hobbes is doing great, btw. Here's a photo of him from a couple weeks back:

I've been keeping track of his weights in a growth chart, so here's that so far:

Note: It starts at 5 weeks of age, when he only weighed was 8lbs 0.1oz.
He's doing great in his training. Here's a video from  a couple weeks ago (he was 3 months 2.5 weeks old or so at the time) of him showing off some tricks. He's even better now, but I've been too busy to make any new videos:


Secondtolastly, it has gotten too cold for my avocado plants that I started growing just before starting medical school, so I moved them inside with a grow light. We'll see how they do over the winter indoors:


Lastly, there's been absolutely no action on the ratmouse trap, so something tells me we were right before - there's a rat living in our sewer pipe. Not sure what to do about that...

Hm.

Well, that about wraps it up, in a somewhat awkward ending to this rambletrocity of a post. Hah.

Monday, October 14, 2013

RATS IN THE PIPES



This is where Wife does (and I, infrequently, do) the laundry. For weeks, Wife very firmly claimed that sometimes when she's in there and it's quiet, she hears something scrabbling inside the pipe, very much like the scraping of a little rats finger/toenails/claws scritching along the inside of a rusty pipe. She was ADAMANT. And I very much did not believe her. Sure, I believed that she thought she heard something in the pipe, but Wife is very afraid of small rodents, and I thought perhaps her fear was running away with her a bit.

I was WRONG.

A little while ago, I was around and accessible when Wife heard the scrabbling in the pipe. I really wish that I had thought to get my phone out and take a video so you could hear the sound, for it is truly chilling. I couldn't believe it was real, but there was no denying it. It was definitely the sound of a rather large rodent climbing up or down a pipe. No doubt about it.

The thing is, that pipe is the sewer pipe that drains the upstairs shower, sink, and toilet. It goes down through the laundry room, down through the basement, and beneath the foundation of the house to the city sewer lines. Could it be that there is actually a rat (or God forbid, rats) that live(s) in the sewer and climb(s) up our sewer pipe for a gasp of air??? What happens when we take a shower, or flush the upstairs toilet? Does it just hold its breath and hold on for dear life? Does it get washed away? Worst of all - does it open its mouth? I have been mulling this question over for a while now, and I think I've figured it out.

Wife and I were so preoccupied with the fact that it sounds like there's a rat in the pipe that we just believed/assumed that there actually a rat IN the pipe. We neglected to consider one thing, which struck me just a few minutes ago, prompting this blog post. What if the rat is climbing outside the pipe? I went down to the basement, and sure enough - the outside of the pipe in the basement is much rougher and rustier, would produce exactly the sound we'd been hearing if a rat climbed it, and is much more likely to have a rat climb on it than to have a rat climbing up the inside from the sewer system. It's very possible we have a rat in the house. Possibly a really large mouse, but from the amount of noise it makes, I'm betting a rat...

It's very possible we have a rat in the house.

So, this evening I placed a rat trap just so:



After placing it, I informed Wife of my conclusions. It's probably not a surprise to you that she absolutely freaked out at the possibility that what she had been hearing was most likely not in the pipe, but just a couple of feet below her feet... After the announcement, Wife actually chided me for not recording her reaction, as it truly was classic. I completely agreed, hindsight being 20/20. The good news is, I thought of something better.

I gave Wife a choice:

1. I could go pick up the rat trap and put it away, allowing the rat (or mouse) to continue living happily a couple feet below where she cleans our clothing.

2. I could leave the trap there, hopefully killing the ratmouse. Once it is dead, I could record her reaction when I bring it upstairs to show her. I could then post that reaction here on the blog so that it is easily viewed/remembered years from now.

Wife wasn't the biggest fan of having to choose between these two options, but I was fairly relentless. After saying, "Neither!" about thirty-seven times, Wife finally blurted out, "Dead rat! Always the dead rat!" And that sealed the matter. Once the trap is sprung and a ratmouse gets caught, there will be a delightful video that gets posted online... Also, there is very little danger of Wife discovering the trap and ruining this fantastic opportunity. You see, she was scared enough of the basement before she thought anything might be living down there. Now, she'll be sending me down any time she needs something. Worth it?

Yup.

Sunday, October 13, 2013

Shadowed in the ED!

On Friday afternoon / evening I shadowed in the emergency department at one of the hospitals in the area. While it was (according to the resident I was shadowing) one of the slower nights in a while, it was still pretty awesome to me. Best thing I learned all night - I am definitely still VERY interested in Emergency Medicine. It's been a loooong time since I set foot in an emergency room (without arriving in an ambulance), and it was just what I needed to help stay motivated this semester.

I did the shadowing as part of an elective course (that's right - I get to shadow FOR CREDIT. In the emergency department!) that consists of three, 4-hour shadowing ops. All I have to do for each one is write a one-page summary of an interesting case for each shadowing session. In the meantime, I get to gain some exposure to the various emergency departments and physicians in the area.

The... highlights... (not sure if that's the best term, given the context, but anyway) from Friday included:

-  A seriously inebriated (BAC = 0.38) patient who threatened the life of a pregnant resident physician.

-  Getting to watch a fourth year med student do his first lumbar puncture (seriously can't believe that'll be ME in two years), getting it right with stunning success on the first try.

- A middle-aged hypertensive patient who had some crazy swings in consciousness (incredibly lethargic and hardly responsive at all one minute, then alert and oriented the next) who ended up going home after a CT and LP showed absolutely nothing wrong...?

-  A patient with a brain infection, kidney stones, and hallucinations (talking to deceased relatives).

It was a great night overall. Even though I'm not allowed to do anything (nor should I be, since there's nothing I know how to do other than take blood pressure and do general examinations to minimal effect), I liked it so much that I didn't really want to leave at the end of an (ahem!) slightly extended stay. But, the physician's shift was ending, so it was time to skedaddle.

This week is going to be packed, and it's only one week till the Musculoskeletal Domain exam. You know, how bones, cartilage, and muscles work; tumors in bones, cartilage, muscles; and diseases of bones, cartilage, and muscle... Yeah, you get the drift. We only have two weeks total to learn this material, and I don't exactly feel like I'm halfway there at the moment. I plan on getting a good night's sleep tonight so I can hit the ground running this week. Note: "hit the ground running" = "severely deprive myself of sleep for the next seven days."

Later!

Monday, October 7, 2013

Infectious Disease is DONE!

A snapshot of my annotated First Aid for the USMLE Step 1.
I might be am definitely including too much information...
But it's working so far, so...
Hmm.
Hooray! Infectious Disease is DONE! I've heard about the horrors that comprise the Hematology / Oncology domain, which is coming up fast, but right now I'm just reveling in the fact that ID is out of my way. Going into this morning's test, I was just hoping and praying for a pass. I really did NOT feel like I knew the material well. And this is after a weekend full of cramming following three weeks of studying pretty hard. Bugs and drugs just haven't been my thing historically, and this exam was almost completely that, with a little immunology, ethics, and epidemiology thrown into the mix.

Amazingly enough, I am happy to say that I not only passed, but managed a strong mastery of the material. For various reasons, I decided a while back that I won't be sharing my exact scores here on my blog. It constantly surprises me who (after being introduced to me) shares with me that they've "been reading for a couple of years now!" or that they "think Hobbes was just the cutest when he came home for the first time!" It's definitely flattering and fun that so many people are reading, but since it's not the hardest thing in the world to figure out who I am, it can't hurt to keep some modicum of opacity to things...

Enough of that kind of talk. Today was awesome, on the whole. After the exam, we always have an hour of PBL to kick off the next domain. If you're looking for an idea of how first year is different from second year here at MSU CHM, I wrote a post on it a little bit ago. After that, we have the exam review session, where we can compare our answers on the exam questions with the correct responses, challenging (in writing) the questions that we think were wrong / flawed / unfair. They usually give back a couple of the questions, marking them right for everyone. Let's face it - most med student's are pretty smart, and they'll find the one place in the textbook that makes multiple answers to a question true. That's just how we roll.

After that, it was off to The Omelette Shoppe with me for some alone time, just me and a fiction book. I know, it's a bit ridiculous that this is how I blow off my steam but... Whatever, I enjoy my food and reading time! Plus, after that I went back and took Hobbes for a 2.2 mile run. I'm a bit out of shape, and he's still got puppy legs, so we're a pretty even match at the moment. The rest of the day was full of television, catching up with communication a bit, time with Wife, and puppy class as a family. Hobbes graduated from puppy kindergarten tonight, which was great. I'm glad to be done with that experience. It was great socialization, but Hobbes didn't really learn much from the whole thing other than what it's like to be humped by Bleu for an hour every Wednesday night. It was good for us to do, as we learned some good training techniques, but overall I'm glad it's done! Unfortunately, this means Hobbes is firmly into adolescence, and the trainer warned us that there would likely be some "regression" in training if we don't keep up with things. I don't think this will be a problem for Hobbes, as he was the star pupil, but you never know...

All right, enough for now. Tomorrow is the real kick-off to the Musculoskeletal Domain, starting with four hours of lecture in the morning, followed by shadowing my mentor for a few hours. Wish me luck!

Thursday, October 3, 2013

Ethics Essay - "Killing" vs. "Letting Die"

In the second year here at MSU CHM, we take an ethics course for the first half of the first semester. This mostly involves reading ethics articles, writing ethics papers, and talking everything over. I don't know whether or not most med schools do this kind of thing, but I'm willing to bet that the places which have an Ethics class aren't quite as in depth with it as CHM. We're split into small groups of 6-8 students per group, and each group has a preceptor, usually a clinician. We meet only once per week for two hours. The class only lasts eight weeks. During those eight weeks, we have to write at least five of the eight possible "Weekly Essays." The topics are prescribed, and the grades for these essays comprise the bulk of the course grade. My understanding is that the course isn't really designed to be difficult to pass, but it's more designed to make you think about things from different perspectives, gaining an understanding of what clinical ethics is along the way.

This week, the essay took its springing point from one of our online lectures, which outlined an argument for claiming that there is an important difference between "killing" and "letting die":


“Killing is an action, where directly causing the death is the goal of the action. Letting die is a failure to
act, where the resulting death is not the primary goal.” Construct an argument that shows either that 1) this is not a defining difference between “killing” and “letting die”; or 2) that it is not an ethically important difference; or both. (Critical reasoning) 

I gave it a whirl, and it wasn't the easiest paper to write, since for the most part I agree with the prompting statement. A lot of old-school physicians would probably agree wholeheartedly with the idea that there's no difference between killing someone and letting them die. This was actually the opinion of a doctor we saw in a video from the 70s who refused for more than a year to allow a total-body-burn victim to refuse treatment and die. That doctor very clearly said that by allowing his patient to refuse treatment and die rather than doing the procedures of which he was capable, he would effectively be murdering his patient. He never considered the concept, as explained by the interview with his patient in the same video, that there are worse things to experience than death. There's a big difference in culture between medicine today and medicine 40 years ago. Back then, doctors more regularly had greater power to do everything they could to save a patient than we do today. Patient autonomy is much more highly valued in today's medical culture than it was a while ago. SO, I tried to write my article as though it were from the viewpoint of that old-school physician. 

Regardless, I constantly felt like my essay was full of holes even as I was writing it - holes that, if I were actually arguing against what I was writing, I would gladly exploit. I think this was the point of the experience, since given that most doctors have to "let die" all the time, most doctors would probably agree that there is an ethically important difference between that and "killing." Anyway, here is the essay I ended up turning in. I'm really not looking for comments on this post - this is more for my recollection years from now about what kinds of things we did in Ethics class. :)

----------


            To discuss whether or not there is an ethically important difference between “killing” and “letting die” based on the proposed concepts that “Killing is an action, where directly causing death is the goal of the action. Letting die is a failure to act, where the resulting death is not the primary goal,” we must first define two concepts. First, the concept of an “action,” and second, the concept of what defines an “ethically important difference.”
            I propose that an individual’s “action” is any operational course taken by that individual with the expressed or unexpressed intent to bring about any single or multiple consequences. Of utmost importance is the concept that a choice by an individual to subscribe to a course of inaction also constitutes a course of action.
I also propose that we define an “ethically important difference” as one that is in line with Lo’s definition of clinical ethics. Lo states that “[w]e use the term ethics to refer to judgments about what is right or wrong and worthy of praise or blame.” (Lo, Ch. 1). The context of this statement by Lo is one of judgment about what is right or wrong in a moral setting – not one of clinical correctness. As such, an “ethically important difference” must be one that differentiates between operational courses in a manner that allows their categorization by intention as either morally right or morally wrong.
            In applying the above rationale regarding ethically important differences to a proposed operational course, the morality of intention of that operational course must be carefully considered. The morality of the operational course is determined by the goals motivating the selection and implementation of that course, and whether those goals are right or wrong. Here is where a key factor enters into the equation. The goals motivating a rational and capacitated individual’s selection and implementation of a particular course of action will include both the direct and indirect effects of that action. As rational beings capable of gauging cause-and-effect, intellectually capacitated human beings are capable of assessing the intended primary and a reasonable number of the subsequent “ripple” effects of their actions. That is, with careful consideration, most humans are able to recognize the direct and most indirect outcomes of their actions.
            In the context of this argument, I argue that (as rational, intellectually capacitated human beings) physicians are capable of conceptualizing both the direct and indirect effects of a given potential course of action. Thus, both the direct and indirect effects of a potential course of action must be factored into that which constitutes the physician’s goals, or intentions, as he or she selects among various proposed operational courses. Additionally, any action that is intended to cause the direct or indirect death of another individual must be termed immoral. By Lo’s definition of clinical ethics, any action in this way deemed immoral must be of ethical significance.
            Having established these definitions and logical relationships, I return to the discussion at hand. I have shown that choosing a course of inaction in essence constitutes choosing a specific course of action. I have also made the case that, for a rational and intellectually capacitated individual, the motivation behind any course of action must include the intended outcomes, both direct and indirect, of that course of action. Just because a foreseeable outcome of an action is indirect in nature does not exclude that action from possible moral and ethical consideration. Thus, if the death of another individual is an intended, indirect result of action, then that action is considered immoral and, by Lo’s definition, of ethical significance.
There is no “ethically important difference” between “killing” and “letting die” in the context of the statements that “Killing is an action, where directly causing death is the goal of the action. Letting die is a failure to act, where the resulting death is not the primary goal.” By choosing to act via inaction in a way that intentionally results in death effectively equates “letting die” to “killing.” In such a context, the only difference between these two terms is one of spelling and semantics. Ethically, there is no difference between them. They are both courses of operation that intentionally result in death.


Tuesday, October 1, 2013

The Health Insurance Marketplace - HealthCare.gov



During a study break today I read a very informative article by the Washington Post about how our government has shut down a large portion of its services because it can't figure out how to fund itself, I thought I'd take a second to see what kinds of options the new health insurance marketplace offers. I was hoping to find an instance of our government succeeding to counteract this failure... I wanted to compare my new options with the health insurance I currently have through MSU. As it turned out, even in this "virtual marketplace" where there are "no lines," I had to wait. In a virtual line. FOR TWO HOURS. 

But I can get past this - assuming it's not (as my friend Antonio put it) a "marketing strategy to make people think everyone is rushing to get it," haha. Who knows - maybe they really did underestimate the amount of bandwidth the Uninsured of America would need to be able to view the site on roll-out day. Anyway, once it finally let me into the website and I made it to the third page of account creation, I had to select and answer some security questions. The problem was, the web page didn't work. Nothing happened when I clicked on the drop-down boxes to select security questions. They just flashed, and nothing selectable appeared, not even a blank drop-down menu. I clicked "Back" and reloaded the page. Nothing. Two hours of waiting completely wasted. If I tried to skip this step, a red error message showed up under the "Answer 1" field telling me that this field is required.


FAIL.
So, I was left with no choice other than to close the page and call it a wash, starting another two-hour waiting session to see if another browser would work. I'm just glad I'm not a single parent working part-time who doesn't have a computer and so went to the public library and waited for two hours to try to enroll for insurance for his kids, only to have this happen. Because you know that if this happened to me, it's happening to loads of people all around the country right now.

Sunday, September 29, 2013

Adult Hospital Visit Experience - Clinical Skills

Tomorrow I have my Adult Hospital Visit clinical experience. In this organized experience, I will go to the hospital and take two hours to talk to a patient, learning about his or her medical history and the history of the present illness. I will be responsible for learning basically anything relevant to that patient's medical reality - family history, social history, allergies, medications, symptoms, etc. Then, I will perform a core physical exam. Remember the one that I learned last year? Well, time to put it to use! It has been a while since I did it, but I've been surprised at how fast it has come back to me with just a little review.

Anyway, after completing the core physical exam, I will be making an oral report to either a resident or an attending. They will have been floating around and observing as we interview and examine the patients, and they will no doubt already know everything that we should have picked up from the interviews and exams. After the oral report, the docs will critique us, telling us what we did wrong and (hopefully) what we did right. I've also heard that they will give us tips for how to do things more effectively during the actual physical exam. I'm looking forward to this part the most, but it's probably also the part that makes me the most nervous. Presenting a REAL patient to a REAL doctor for the first time. Stuff's getting real...

After presenting to the physician, I and my fellow med students will need to write everything up in a complete History and Physical. It's this rubricized (fun new word, that) way of recording everything that we gathered and reported into the patient's health record. Granted, they would never actually use anything created or written up by second year medical students on their first actual attempt at this, but we need to do it like we're serious. Because, after all, we are getting a grade for this - even if it's only two percent of our total Clinical Skills grade for the semester.

All in all, it should be fun. Wish me luck!

Saturday, September 28, 2013

The Fever Box

Replace that handle with a head hole, and you've got yourself a Fever Box!
So, I just learned that the treatment for syphilis wasn't always as nice as it is today. These days, we just give penicillin. Poke, ouch, done. If the patient is allergic to that, then we give erythromycin or doxycycline, which work just as well. The thing is, penicillin wasn't discovered by Fleming until 1928, and the other drugs are even newer than that. Before 1928, doctors used a "fever box."

What's a fever box? It's a completely enclosed box with a hole cut in the end for your head. You are placed in the box, and then the box is placed outside in the toasty hot sun. You see, treponema pallidum, the spirochete (a corkscrew-shaped bacterium responsible for syphilis) is really sensitive to deviations from the human body temperature. Unfortunately, it's so good at evading the immune system that our bodies don't react with a fever the way they do when we get infected by most other bacteria. If we did, that fever would kill off Treponema pallidum. So, the good docs of the early 1900s would stick you in a fever box to force your body temperature up, giving you a pseudo-fever that would (hopefully) kill off the bacterial infection. Either that, or dehydrate and kill you first... Just kidding - no clue if that ever happened, but I suppose it's possible.

Regardless, sometimes it just hits me how far medicine has come in less than a century. This is perhaps not even the best example, but it's not a bad one. So to all the syphilis patients out there - be glad for Alexander Fleming and penicillin. Otherwise, you + syphilis = no fun in the fever box.

Tuesday, September 24, 2013

Infectious Disease = Rote Memorization

How do I feel about Infectious Diseases?


I understand this is a common reaction, coming out of the Neurology Domain. I mean, Neuro was awesome; everything was still (relatively) fresh in our minds after taking Neuroanatomy last Spring, and I feel like it's a fairly small minority that came out of Micro the same semester thinking, "Wow, I really learned all of that!"

ID feel very much like the big brother to Micro, but with much less hand-holding. The Sherris textbook has become my best friend, with Goodman & Gilman (Pharmacology) and Robbins (Pathology) rounding out the textbook gang. No matter how much I look up and learn in one day, I have yet to go to bed once during this domain thinking that I made it through enough of the material. Quite the opposite - even after a 12 hour day, I go to bed with a sinking feeling accompanied by the mantra, "Okay, tomorrow I'm really going to have to kick it into gear..."

I used to think I was good at rote memorization - then I came to medical school and learned that what I had thought was rote memorization was actually very logical and well thought-out in comparison. For example, before medical school I thought rote memorization was just memorizing that macrophages swallow big chunks of stuff and digest it. That's not rote memorization, because all of that is in the name - "phage" comes from "phagos" (or phagia or whatever) which means "to swallow," and macro means large (because macrophages are fairly large or because they swallow large things, whatever floats your boat). The meaning is in the name. 

What we are memorizing now are things like this: T cells are a kind of lymphocyte. Immature T cells (and B cells, the other main lymphocyte) need the Rag1,2 genes to be able to mature/differentiate into the next stage of development. Immature T cells can go to CD4+ (helper T cells) or CD8+ (cytotoxic T cells) cells. CD4 and CD8 are specific receptors on the surface or T cells. Antigen-presenting cells (APCs) express MHC-I or MHC-II molecules, which help show off bits of pathogens to the lymphocytes. CD4+ T cells interact with MHC-II molecules on APCs and then further differentiate into Th1 or Th2 cells, depending on which signaling molecule gets secreted by the APC and acts on the CD4+ T cell. If it's interleukin (IL) 12, then the CD4+ T cell differentiates into a Th1 cell. If it's IL-4, it differentiates into a Th2 cell. Th1 cells secrete more IL-12 (to help other CD4+ cells differentiate into Th1 cells) and IFN-γ, which activates macrophages and CD8+ T cells. Macrophages then secrete TNF (tumor necrosis factor), which calls in monocytes to help chew up or sequester dead / infected / dysfunctional / foreign cells. Th2 cells secrete more IL-4 (which does double duty in helping CD4+ cells differentiate into more Th2 cells as well as helping naive B cells isotype switch into IgE-producing B cells) and IL-5 (which helps naive B cells isotype switch into IgA-producing B cells). Those immunoglobulins have different functions and act in different areas. For example, IgA is present in serosal and mucosal surfaces and acts to bind epithelium-binding receptors on the surface of bacterial pathogens so that they can't bind to epithelial cells and get in through your nose skin. IgE plays important roles in cross-linking antigens on the surface of mast cells to activate them when an allergen is present, initiating histamine release and the reason why millions of people spray gallons of Nasonex up their noses every year.

So yeah. THAT is rote memorization. There's no way to logic it out what Th1 vs Th2 cells do, or which immunoglobulin (IgA vs IgE vs IgG vs IgM vs IgD) can pass through the placenta and thus go from a pregnant woman to the baby growing inside of her. You just have to memorize that it's IgG. 

Sure, we come up with fun mnemonics like Hot T-Bone stEAk for the interleukins, but it's so nonsensical that deep down, it's still rote memorization, just... catchier:

H for Hot is 1st and is for IL-1, which is a pyrogen and upregulates the COX-1 pathway in the hypothalamus to increase the set body temperature and thus causes FEVER 
T is 2nd and is for IL-2 which activates T cells, specifically Th1 cells and thus CD8+ cells as well 
B is 3rd and is for Bone marrow, which is stimulated by IL-3
E is 4th and is for IL-4, which stimulates isotype switching in B cells for IgE
- A is 5th and is for IL-5 which stimulates isotype switching in B cells for IgA

THAT is rote memorization at its best.

Aaaand, back to studying ID...

Sunday, September 22, 2013

Flashback: Hobbes' First Bath & Photo Recap


This post is 100% for the sake of perspective as time goes. It's so easy to lose track of things when you're as busy as Wife and I am these days. 

Here are some photos since then:






I've been weighing Hobbes almost every day, just because I felt like it. I like seeing trends extrapolated over time. It's probably one of the nerdiest things about me. In college, I kept track of my score in every game of frisbee golf I played over four years in an excel spreadsheet. This trend of mine is also probably the reason why I like time lapse videos so much. Anyway, I'll upload a chart Hobbes' growth over the first six months this coming December.

For the first month or so that we had him, Hobbes slept in a laundry basket by our bed. I think this was his last night sleeping in there before we moved him to his crate. It was getting a bit cramped...

Believe it or not, he actually slept in this chair like this for about 45 minutes.

As part of our series of "last hurrahs" before starting school this year, we went on a kayaking trip down near St. Joseph.
Hobbes LOVED it - though probably not so much when I pushed him in...

Hobbes saw more of this country at two months of age than I probably saw in my first 15 years on our road trip to Rocky Mountain National Park in Colorado.

I took this photo last week. It's hard to see how tall he's getting from this photo, but trust me - at over 25 lbs, Hobbes is definitely getting bigger. If it helps, he was 8lbs 1.0oz in the video at the top of this post.

Wednesday, September 18, 2013

Blammo - Done with Neuro

This man looks how I feel. Ironically, it's an image from a Migraine and Cluster Headache Clinic's website...
Neuro is done! My first PBL Domain at MSU CHM is DONE. Results are in on Monday's exam, and things went pretty well. Yesterday I did my Neuro Practice Based Assessment, in which I completed a full (recorded) neurological examination on an actor paid to fake a case. After interviewing and examining the patient, I had 1.5 hours to complete a SOAP note (click here if you want to and don't know what this is) and submit it for a grade. The whole experience isn't worth much as far as my grade in Clinical Skills goes (only 2 points out of 100 total; each exam is worth 44 points), but I would say this was probably one of the most valuable clinical skills experiences that I've had so far. It was actually kind of fun, trying to find the right balance between taking enough notes and holding enough information in my head so that I was still being courteous and communicative toward the patient.

I haven't gotten the grade back from the Neuro PBA, but that will probably take a week or two, since it's graded by third- and fourth-year medical students - all of whom are probably WAY busier than me. Next year has been sounding quite daunting recently. Right from the beginning of third year, we are scheduled on really loooong shifts at the hospital. Like, I'm talking 24-30+ hours long. While we won't really be doing as much as the residents and attendings, we will still be part of the team and trying to absorb everything going on around us. I'm very excited about it, but I can already tell from talking to other people that it's going to be an even bigger shift from the current (M2) year as the M2 year was from M1.

The current PBL (Problem Based Learning) Domain is Infectious Disease and Immunology, which means I've gotta dredge up a boatload of Microbiology that I hopefully have tucked away in some dark corner of my brain. B cells? T cells? Dendritic cells? Viruses? Yeah... It's going to take some reviewing to get back in the swing of things, but luckily that is why they give us all of this excellent time. My schedule this semester is actually working out pretty well. My weeks are heavily front-loaded, which means I'm absolutely slammed on Mondays and Tuesdays, but Wednesdays through Fridays are fairly light, schedule-wise, so I have the time I need to really delve into the material before the weekend hits. All right, back to it. Wish me luck.

Friday, September 13, 2013

Gearing Up - How I Do Neuro

I don't think there's much out there that could be further from gangsta-style, but this is how I roll.
Click to embiggen.
Monday is the Neuro Domain exam here at MSU CHM. We are told to expect ~30 questions on the exam for each week of the domain. Since Neuro was a three-week domain, we can expect approximately 90 questions, with exactly 2.5 hours. This boils down to about 1 minute and 39.6 seconds per question. This is actually not that bad for normal questions - except this is med school, so these aren't "normal questions."

Which means we've got to know this stuff.

And thus continues the marathon of studying that is medical school.
Wish me luck.

Thursday, September 12, 2013

End of Neuro and Practice PBA

Though the tie isn't shown that well, this is just proof that I dress up for these simulated clinical experiences
It's crazy, but the Neurological Domain is at a close. What?! Apparently it's been three weeks - which have absolutely SCREAMED by. Fast, folks. Today I have my (recorded :/ ) Neuro Practice Performance Based Assessment. Basically, I and another student take turns being the student doctor or patient. As the student doctor, I greet and do the niceties, then find out why the "patient" came in today, obtaining a relative past medical history and all the subjective, self-reported details about the fake symptoms that my classmate is experiencing.

After finding out his symptoms (we're paired with members of the same gender), I will conduct the Neurological Exam, looking for deficits in cognitive, motor, and sensory function. Basically things like checking to make sure he's alert and oriented, can think, doesn't have sensations when he shouldn't and that he has all the sensation that he should (and that it's the same sensitivity on both sides of the body), and checking reflexes and motor capacity in the head and extremities. Here's a picture of the exam checklist:


After we take turns doing our examinations, we have approximately 90 minutes to write up what's called a SOAP Note. After listing/describing his CC (Chief Complaint) I'll write the SOAP section. SOAP stands for Subjective (what the patient tells me about his health in general and his specific reason(s) for coming in); Objective (my findings / lack thereof from the neurological exam - normally this would also include any other pertinent physical exam findings, but for today we're just doing the neurological exam); Assessment (what I think could be wrong with my classmate based on what I found and included in the S and O sections - gotta include at least three potential diagnoses, ranked in order of perceived probability, along with as detailed of a description of the related pathophysiology as I can come up with at this relatively early point in my education. Also included are things like severity and urgency, prognosis if untreated vs. treated, and any pertinent psychosocial issues.); and Plan (should include what I think should be done diagnostically for this patient patient to confirm / rule out my potential diagnoses; what I think should be done to help treat the patients symptoms and/or underlying condition if my diagnoses are correct; and education of the patient to help him proceed in the management of his condition(s)). 

Following the P section will be a Master Problem list, showing all of the ranked-by-severity problems that the patient is dealing with, as well as timeframe details (past two weeks, since 8/10/09, etc.) for each. And that's it for now. Simple, right? Not too complicated, but when you throw into the mix the facts that 1.) I have yet to memorize the above list (I've still got 4 hours, so have no worries ;)) and 2.) I've been spending almost all my time studying for the Neuro Domain exam this coming Monday, it gets a little dicier. Luckily, this is merely a practice session - all grading and feedback is merely formative in nature. The actual, graded Neuro PBA will come on Tuesday, the day after the Domain Exam.

If you're not familiar with how second year at MSU CHM goes, we learn pathology by domain (neurology, musculoskeletal, infectious disease, hematology/oncology, etc.). At the end of each domain, we take one huge (3-5 hour?) test, and that's our grade for that domain. If we don't get a 75%, we take a remediation test. If we don't get a 75% or higher on that one, we have to extend our medical education by 1 year to retake that domain next year. Stakes = high.

And with that chilling concept seeping deep inside my bones, I'll get back to studying. Later.

Saturday, September 7, 2013

Cancer, Learning, Grief, Grandpa

We've been learning everything about Neuro lately, and the past day or so I've been focusing on neoplasms of the CNS and related structures. So, brain, spinal, and peripheral nerve cancers. I didn't anticipate this being as tough for me as it has been.

You see, my grandpa passed away this past spring. His cause of death was mostly complications due to multiple foci of metastatic cancer in his brain. Though dozens of tumors were also present in his chest and abdomen, the cause of death was the cancers spreading and swelling in his brain. With his death and funeral still fresh in my mind, it takes on a very different feel to be now learning about how cancers can move to and grow in the brain, the symptoms that they can cause, and what the brains of the deceased look like when riddled with cancer. When I'm presented with images like the one below, it's hard to not think of that brain as Grandpa's brain.


This one is particularly rough for me - the caption read:
"Coronal section showing multiple metastatic neoplasms at the junction of gray and white matter."
Death is such a strange thing, and the closeness of this domain content to my own personal loss is hitting me very hard. It's one thing to contemplate the idea of death, and the blanket statement of how "everyone is going to die someday." It's something completely different and strange to need focus on and learn the intricate details about the disease that caused someone close to you to die. Feelings of grief and loss well up unexpectedly, shattering concentration. This grief is still a tender thing for me, not easily wiped away or swept under the rug when it resurfaces.

I'm still learning how to work through things like this without bringing up feelings of sadness and personal loss. I need to figure out how to study this without thinking about the fact that I can't talk to my grandpa on the phone anymore, how I can't ask him any more questions about my ancestors and where I come from. It has helped quite a bit to write these feeling out here; maybe it will be easier for me to move past them for a time. I never anticipated this blog as being something therapeutic in any way, but there it is. I suppose it's all part of this "Transformation," which in the whole purpose to the blog in the first place... Thanks for reading.

Wednesday, September 4, 2013

Second Year (M2) at MSU CHM

Yeah, this is a random photo that has nothing to do with the topic of the post. I just wanted to toss in a picture of me and my Nony (Americanized-Italian for 'Grandma') from the MSU CHM's White Coat Ceremony last year. It's hard to believe that was already more than a year ago. Some days it's dragging, but most days med school is just flying by...
To nostalgia!

I'm now in the thick of the first "domain" of my M2 year here at Michigan State University College of Human Medicine. For those that aren't familiar with how my school rolls, it's like this:

First Year: lots of structured, didactic-style lectures. You're getting in most of the basic science you'll need for next year. Your classes are things like Microbiology, Gross Anatomy, Biochemistry, Genetics, Neuroanatomy, Physiology, etc. Most are optional, but there are required, scheduled lab times for both Anatomy and Histology. I think it was something like 30-40 hours of scheduled lecture, clinical skills, and lab time each week. You're learning how the body is supposed to work. You have to spend a lot of time watching lectures, taking notes, and going to lab to memorize all the body and cell parts. This adds up, so when I say a lot of time, I mean that's pretty much all you do. Add in some clinical skills experiences and learning how to do the core physical exam, and that's pretty much your first year. Lots of lectures, lots of lab, lots of passive learning.

Second Year: A LOT less time is spent in lecture, and no lab. We learned all of Anatomy last year, right? At most, we have eight hours of didactic lecturing, in four-hour blocks twice a week. We also have three, two-hour chunks of time devoted to Problem-Based Learning (PBL). Basically, work in groups of about 8 students with one physician preceptor and work through imaginary cases in the "Patient is an (age)-year-old (race) (gender) who presented in the ER with (symptom1symptom2symptom3)" style. We pick out "cues," formulate lists of hypothesis of diagnosis, and come up with learning issues (things we're not quite up-to-snuff on and need to learn better to be able to firmly diagnose the patient) - all on the first day. Then, we all put our hands in the middle of the conference table and shout, "BREAK!" before heading off to learn everything and come up with a concrete diagnosis. Right? Right.

In first year, we could completely rely on printed coursepacks created by CHM. If it wasn't in the coursepack, we didn't need to know it. Things are different this year. The coursepack helps serve as a guide to the topics that we need to learn, but it doesn't go into nearly the level of detail that we're expected to know. For that, we have supplemental readings and recommended chapters from textbooks. Apparently this first unit (Neuro) has a much more comprehensive coursepack than later units, as we've been heavily encouraged by M3s to enjoy Neuro while we can.

And that brings me to the structure of the second year. Aside from a half-semester Ethics class now (and a half-semester Epidemiology class later) and Clinical Skills, all we have is PBL, which is split up into domains based on body system. So, right now we're doing Neuro (3 weeks), which ends with one big test. The tests have about 30 questions for each week of domain length. So, the Neuro exam will be 90 questions - and that's your whole grade for the domain. If you get less than a 75% on the exam, you get one chance to take a remediation exam and get a "CP" (conditional pass) grade, which is acceptable, but doesn't look the best on your transcript. If you don't pass the remediation exam, you have to retake that domain, which means that you have to extend your medical education by a year.

Let's just hope that's not something I have to deal with, hey?

So there it is - we have a lot more "free time" this year compared to last year, but that just means we have to be even more self-motivated to study and READ everything that we need to learn. To give you some idea of it, the Neuro coursepack is 690 pages long, and mostly deals with the pathologies you might encounter in the central & peripheral nervous systems. Aside from a light review in the first couple days, we're expected to remember most of the physiology and anatomy from last year. Also included in the domain are many relevant "Bugs and Drugs," all of which either cause or treat those various pathologies of the nervous system. Lots and lots of supplemental reading, memorization, and time spend with your nose buried in books at home or sequestered in study rooms.

We have a lot more self-structured time in second year, but a lot more to learn in that amount of time. Speaking of which, this is turning into a rather lengthy post, and I have about 100 more pages that I'd like to get through before bed tonight. Probably not going to happen, but there it is. Today was spent differently than I would've liked, so I'm a little behind... 2 hours of Neuro PBL, 2 hours of Ethics, 3 hours volunteering, 2 hours of group review/study/case practice at the Secchia Center, and 2 hours of studying at home so far. Add in the time spent eating, ambulating, and trying to get Hobbes to stop peeing on the floor, and you've got a full day...

Back to the books. Wish me luck.

Sunday, September 1, 2013

Colorado Road Trip - Estes Park, Rocky Mountain National Park - Photos


So, before I got hospitalized, Hobbes, Wife and I took our last week of freedom summer and went on an impromptu road trip to Colorado. Neither of us had ever seen mountains in the United States (Wife had seen a bit of the Alps before), and we figured a few days of mountain air would do us good. And we were right, minus the intestinal infection I somehow contracted on the drive out (most likely at a rest stop). We spent about five days on the trip: 1 day out, 3 days camping in Estes Park: East Portal Campground and driving through the Rocky Mountain National Park, 1 day back.

Since my second year of med school is in full swing, I don't have time to caption these photos, much as I would like to. However, I'm going to want to have written about this experience once November rolls around and the summer begins to seem like a distant pipe dream of bliss. I'm going to want to remember that it WAS real and I really DID go on a road trip and have an awesome time and that life is NOT just endless studying in preparation for Step 1 (and someday being a doctor). Without further ado, here are the photos:































































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