We ain't in Toto any more, Kansas!

So I worked at the HRC yesterday. The Health Resource Center (HRC) is a clinic in north St. Louis run by the university. I had never been in North STL before, and it's another world north of forest park. There were boarded up houses, groups of idle teens, trashy stores, overall slummy. You couldn't pay me to live there, that's for sure. Scary, but it was also really sad. You could see these formerly nice homes, that had once looked exactly like mine, had completely fallen into disrepair. The clientelle of the clinic was also discouraging. Yesterday we were doing physicals for teens who were in a rehab clinic. They were 14-16 year old boys who were concerned about gettting tested for HIV, chlamydia, ghonorrea, and syphillis. They didn't phrase it that way, they just said "I want to get, you know, tested". For what? I would ask, not really knowing where they were headed with this. Looking aside, they'd just say "you know." Being a clueless naive white middle class kid, I would just note that on the history and report it to the attending. The attending was really cool and had a good rapport with these kids. He had gone to Howard (a traditionally black medical school in DC), or at least had scrubs from there, had dreds down his back and could talk with these kids in a way that I couldn't. For him it was implicit that these guys were concered about STD's. His advice and instructions for these guys were not directives, nothing along the lines of "you need to stop sleeping around before you get HIV", but instead he would tell them that they were young and otherwise healthy, and it would be a shame to ruin that by smoking more or not using condoms. The rate of HIV in the black population of St Louis is something like 4 times the national average, and is among the highest in the nation.

What I Do For Fun

Sometimes, Chancho, when you are a man, you wear stretchy pants, in you room. Is for fun. Well, perhaps I don't don red briefs over baby blue tights and a cape. Instead when I 'm not hunched over Netter and NetAnatomy.com and my syllabus, I play the piano. Sometimes Mindy helps me, but usually it's just me. It's a lot easier to sit down and practice now that I'm not six. Plus, since I'm not paying for lessons, I don't practice if I don't want to. I get the fun of playing without the drudgery of playing etudes over and over. That''s pretty much the only constructive thing I do for leisure. If I'm not doing that I usually just sit around and try to let my brain unwind.
Speaking of brains: we removed the brain from our cadaver two weeks ago. We cut the head in half above the eyebrow removing the calvarium (top half of the head, roughly speaking). Two dissections later, we cut the remaining half again, this time in the coronal plane (the plane between your ears) down past the larynx in order to expose the pharynx and larynx. After that, we cut from the nasal cavity through to the palate to expose the sinuses. By the end of that block, the upper half of our cadaver was bareley recognizable as human.
Why do I mention this? Until the early 20th century, medical dissection for learning by students was taboo. Yes, dissections were social events during the Enlightenment, and to some degree in the Renaissance as recorded by Rembrandt in his famous (but anatomically erroneous) painting the Anatomy Lesson of Nicolaeus Tulp. The subject in those times was a publically executed criminal for whom the post-mortem dissection was the final step in his shameful demise. At our school we have over 400 bodies donated annually of which the MS1's get to use 28 for dissection. In October we have a memorial service for them to which the families of the deceased are invited. It's a great thing to be able to dissect a body and learn from it. There is no substitute in my mind, since atlases and even 3D computer models are only partial views.
Some authors claim that the cadaver-student relationship is preserved in the modern age of CT, MRI, 3D model etc. in order to familiarize the student with the nemesis of their chosen profession, death. The dead body in front of the student supposedly serves as a reminder of what will ultimately come to pass for every patient, regardless of short term interventions. I can't speak to this, since I have virtually no experience in clinical medicine. Frankly I didn't view the intial incision down our cadaver's back (which I made) as particularly cathartic. Yes, it was a little odd to cut the skin of another human being, but I have been sticking foreign objects into the living for 3 years. Frankly the hardest dissection for me was not the face, that was more of a pain and challenge than anything emotional. Dissecting the hand was a stranger experience. The hand is uniquely human, and the cadaver on which I was working still had on nail polish, which made it more difficult to distance myself from her humanity. She still had the poke marks in her fingertips from the blood sugar lancets, marks which I inflicited thousands of times as a phlebotomist.

All's well that ends well

Short version: I passed my first anatomy exam. Yay! It feels odd to have a different bar to aim for than as an undergrad. The stakes are higher and so is the bar in medical school. In college I consistently tried to ace every exam and get at least an A-. Things are different now. I'm glad I passed, and since the exam was so hard, I know that I'm lucky to have been able to. Shoot for the P, since Honors isn't happening in this class.
We had some strange units in class this week. We covered the topography of the skull and the cranial nerves, both of which will be covered to exhaustion in later units. Consequently, right after the exam it was hard to jump right back into the long study hours. I don't think that I was resting on my laurels (such as they were), but having such general sections kind of threw me off my groove.
Some of the hardest stuff to master this week, and I have by no means mastered it, was the deep face. The area behind the angle of the mandible (the part of your lower jaw where it changes from horizontal to vertical) is chock full of nerves, arteries and a couple muscles. The arteries are pretty tough because they are quite tortuous in their tracks. While this is handy in allowing you to open your mouth without tearing blood vessels, it makes tracing them and their branches difficult. Identifiying structures is doubly difficult because several things are named very similarly if not identically, for instance there are two buccal nerves which arise from totally separate cranial nerves; there is also a hypoglossal nerve, but a hyoglossal muscle. Keeping everything straight is pretty tough. It's hard when there is a long section to learn because you don't have any down time to catch up, you just need to study the next section hard so have a few hours to go back and learn the older stuff again.

At Least That's Done

Well, for better or worse the exam is over campers. I think I passed, at least a cursory review of the practical looks like I got maybe 60% right, which would be ok. The written exam was, to say the least, grueling. I took that part last, after nearly 4 hours of testing before it. I was starving because I was too nervous to eat before the exam. It was extremely challenging, every question was really tricky. Some I had to outright guess on because, to my knowledge, we had never discussed it in lecture.

The questions were mostly clinical vignettes where you had to tease out the relevant facts and answer the questions. There were very few "what attaches to this bone" type questions, but they were a nice break when I could get them. The vignettes would be a few sentences of scenario, followed by a question. Here is an example: A young man presents to the ED after a bicycle accident where he hit his shoulder against a light pole. He has numbness along the outside edge of his shoulder, his pinky, and is unable to extend his wrist joint. What was likely damaged? Then there are 5 closely matching answers, out of which you hope to find the correct one. Did he avulse the top roots of the brachial plexus? did he damage a cord? a terminal branch? which one? were there several nerve injuries that could match this scenario? of these possiblities, you have to figure out the right nerve(s) and hope your answer matches those available.

There was also a slide portion where they showed cross sections of a cadaver, MRI, CT, Radiograph(x-ray), and drawing. The tricky thing about cross sections is that the convention in medicine is to use the inferior view, rather than a superior view. For example if you have a cross section which shows the shoulder joint, you are looking at the section from "below" rather than a bird's eye view from above. The real trickery comes in some of the paintings where you can tell that it's a superior view that has been digitally flipped so that the left and right match an inferior view, despite being able to clearly see the chest as you would from above. The CT's were pretty straightforward, at least in the thorax. My only difficulty came in trying to discern between pulmonary arteries and veins. Check out images 13 and 21 on this page if you want to see some good CT's and know what I'm talking about. #37* and #30 are the vessels in question.

I realize it would be more convenient if I just posted the pictures on my blog, but there are copyright implications and I'd rather not mess around with that.

Marathon or Head Race?

In our Orientation one of the Deans likened medical school to running a marathon. I guess the implied meaning was that you should pace yourself and you should be ready for a long haul and not go too hard in the beginning. I think a more apt comparison would be a head race in crew or even a 2K. In a head race, you row full speed through the starting line and try to have the fastest time over a 5K or 7K course. It’s grueling and it’s hard and it’s full speed all the way, all the time. Studying in medical school isn’t about saving your energy, it’s about going all out, all the time because anything less and you will be passed by the material and your classmates. I feel that way right now anyway. I might change my mind later in the year, but right now that’s how it feels. Currently my mind feels fried (which I guess would argue that you should pace yourself), but I still have 25+ hours to study before the exam on Friday. I know I can learn what I have to, but I don’t want to. I want to sleep. Things left to study
-Cervical plexus: learn which nerve roots contribute to which nerves
-Dermatomes of the arm, hand:
-Muscle insertions on the humerus
-review the heart and lungs for the umpteenth time
-review fascias of the posterior triangle of the neck.


Postcriptum: So, in rereading this, it seems that I have no sense of proportion or balance. Let the record show that I do in fact have leisure activities, among which include playing the piano. I study as much as I think I have to in order to do well and pass. Do I think I'm going to get honors in gross anatomy? no. Do I hope to pass? Yes. Do I study my tail off so that I don't have to remediate anatomy next summer in Omaha? yes.

Shooting the curl

So my other blog had a post that was pretty similar to this. When I'm studying intently for hours and hours for days on end, it kind of feels like how shooting a curl on a surfboard must feel. The schedule is really tight this week because we have an exam on friday, so I have to spend every minute getting ready and making sure that the time is well spent. There isn't a lot of margin for error, as far as wasted time goes. I learned on my mission how to budget my time aggressively, so that skill definitely comes in handy now. Up at 6, bed at 10, 10 hours of study, 3 hours of class and some meals in there. I hope and pray that the pace will back off after anatomy. Either that or I will have learned how to study and so I might have an hour or two more a day that I can take care of the corps physique. It's bedtime so I'm going to dream anatomy dreams.....

Cool Toys

One great thing about medical school is the cool stuff you get to use. In the basement of the medical school building, we have a medical student lounge. There are always two students playing on the ping pong table and we get a lot of mileage out of the air hockey table. On thursday this week, however, we got a really cool new toy. The director of the clinical simulator got his hands on a laparascopic simulator. It’s a combination of high and low tech. The simulator has many of the same instruments used in laparascopic surgery, including hemostats, forceps, clamps, and a stapler. There is a light and camera combo which is just like the real thing, (imagine a magic wand with light and camera at one end and a focussing ring at the other). The whole thing is wired into a tv screen so you can watch yourself on the TV just like in a real OR. The low tech part comes with what we can do with the instruments. The instruments are inserted through holes in the top a wooden box, inside of which is another board with screws, nails, and other objects screwed into it. There are lots of beads and washers and rings and such that you are supposed to practice manipulating with the laparascopic tools. Several factors make this difficult. Having good depth perception can be hard since the screen is 2D and the tools are in a 3D environment. Also it can be difficult to tell what position to put the tools in so that they can most easily manipulate the articles inside. Since you’re working with essentially a long lever, the directions are reversed too. If you move your hand to the right outside the box, the box itself acts as a fulcrum to move the distal end of the tool to the left. You yourself can complicate things by changing the angle of the camera as well. You can rotate it 360 degrees, so you can put the “bottom” of the box on the “roof” if you want, just to test your mental agility. It’s a lot of fun, and I’m glad they put it in the lounge. I love playing with it, the manual challenge is pretty interesting.