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. :)

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            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.

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