The Curious Powers of Jim Halpert

Ok, the title is a refrence to an episode of "The Office" when a bat flies around the office and Jim pretends he's a vampire. At three in the morning Monday, I was wide awake, my body having decided that 5 hours of sleep was about right. By 0530, I was fed up and decided to go for a run. As I was running, a bat flew into my neck and flew off. I didn't feel anything other than an impact, and the sound of leathery wings beating a hasty retreat. So I continued to run, and had a nice 3 mile loop. As I was running, however, the somber words of our microbiology professor kept tapping through my mind in time with my feet. "Most people don't know they've been bitten" "Bats are carriers", and "universally fatal" were the cheering sentiments that filled my wee imagination. I got home, showered, and looked up rabies in my microbiology textbook. I was still debating whether or not to tell Mindy or if I should just shrug it off and go to school like normal.
Thirty minutes later I was sitting in the ER across from school. Upton Sinclare, in his novel "The Jungle", opined that women tend to grow emotionally more or less constantly and gradually, but that men tended to grow suddenly in big sporadic spurts. That description fits me pretty well. It's pretty wierd, suddenly living with the possibility of having a fatal illness. I reassured myself that, as far as I knew, the post-exposure vaccine was very effective, and that, in all likelihood, nothing had in fact happened. Then the comforting voice of doubt would whisper, "but why would the bat fly into you in the first place unless it was deranged?" , and "if the vaccine doesn't work, then you'll die because only one person has ever survived symptomatic rabies, and she had severe neurological sequelae" or "if your neck feels numb or tingles, then you're a dead man, and you'll die right when your little boy is going to be born, and you'll never see him, and his mom's last memory will be of her husband, the deranged, rabid, lunatic who could no longer recognize her through his dementia." Perhaps ignorance can be somewhat blissful then.
At school, all I could do was joke around about it because really, worrying isn't going to make you feel better, so you might as well laugh. I am the inveterate sarcastic cynic, despite my best efforts to reform, so instead, I just whipped up some Alda-esque black humor. After 10ml of IM rabies immunoglobulin, I was pretty sure that things would be OK, especially since I had recieved it about 4 hours post exposure. When I was just sitting quietly in lecture, though, mr. comfort returned with his gloomy prognosis and dismal outlook should I develop 'la rage' as Jean Gaulois would say.

For those who cannot recall their infancy which is when the probably last recieved IM shots in the glute, it isn't too bad, really. I thought it would hurt like the dickens, but the glute shots hardly stung at all. The shot in my quad was no treat, nor the delt, but IM glute is a good way to go, I think . I have to return 3 more times, including tomorrow morning for more shots. After the 28th day, we cross our fingers and wait. Since there are no known failures of post-exposure rabies prophylaxis, I'm sure I'll be penning this blog sporadically for years to come. I do have a strange aversion to garlic, sunlight, and I can't see myself in the mirror anymore really. Oh well, you can't win 'em all. On the plus side, now I'll be able to relate to the plot of "Twilight."

Refractory periods

So, the picture above is of an action potential, i.e the electrical excitation of a neuron. As you can see, there is a sharp spike, followed by a dip which is below the baseline of the initial spike. In this state, the neuron is unable to be excited and initiate another action potential. I would liken the graph to my brain. I studied my brains out in anatomy, took the last test, and have been in a refractory period wherein I can't excite my neurons to study hard again. Our new units are Cell Biology and Metabolism, which are really two sides of the same coin, but are separate classes. Cell bio is mainly histology, or the microscopic study of tissues. Metabolism is going to be protein regulation, and pathways, pathways, pathways. At the moment, we haven't had too much material that I hadn't at least had to some degree in undergrad. I'm actually glad that I studied the binding of O2 to Hemoglobin for 5 weeks in my biochem class. Anyway, back to the refractory period. So in essence, I'm having a hard time gearing up to study with the same intensity. I also have not yet figured out to what depth I need to know the material. In anatomy, it was easy but tedious. You just memorize the 9 pages of syllabus for the day and you were good to go. Right now, I don't have any idea what the best way to study is.

We have a lot of great resources to learn from here. For histo, the best thing we have is virtual microscopy. We have a microscope lab, and I can go there 24 hrs a day to look at slides if I want to. Or, I can stay at home and using my balky cable connection, I can access the same slides online. I can do all the same zooming, focusing, and examination, but with the added benefits of: no headaches from staring through lenses, having a thumbnail image to tell me where on the slide I'm looking, and best of all, labels that can appear to point out what the purple blobs really are. I have a friend who is red/green colorblind, but he seems to be doing ok. A lot to the slides we're looking at are H/E preparations (hematoxylin and eosin for the science geeks) so they're essentially various shades of pink and purple. He alleges, however, that he can figure stuff out from contrast alone, but we're all crossing our fingers he'll be ok.

Things are generally going pretty well, I have my one exam in Biostatistics this week, so I'll have to spend some time away from my main classes studying for that. Fortunately, as long as you study, the exam is reputedly an easy pass. Isn't that they way they all are? as long as you study, you won't have any problems? duh! Well, in anatomy, I don't know how I could have honored it unless I'd had the material before or unless I had a photographic memory, there was just so much in such a short time span. Fortunately, I like chemistry so this stuff now is pretty fun to learn. I might sing a different tune in the next few weeks, but that's how I feel now. It is time, however, that by hook or by crook, I must depolarize my brain again enough that I can study hard this week and get back to work.
-Spiff

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.

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.

Tools and Dorks

So, I wrote of the first week that there were no morons in medical school. I now ammend that statement. They aren't necessarily dumb, obviously they aren't since they got in. They are just lacking in common sense.

Example: If you are a VERY hirsute man, please, don't assume that you are Adonis incarnate. We don't really want to see your furry body as you change into scrubs in lab. We have a locker room or a bathroom that are perfectly suitable to this purpose.

Example 2: If the dissection instructions contain a list of structures to be exposed during the dissection, you can safely assume that those are the things to look for. Don't just skin the cadaver and call it good. The rat's nest of nerves underneath is what we're looking for. See, when the instructions want you to expose the internal jugular vein, it's really helpful for the labmates who aren't dissecting that day if you actually do it, so that we can see the adjacent structures.

Example 3: Cadavers that dry out are like jerky. Please spray them down!

Saturday

Medical school is not a 9-5 affair, nor is it mon-fri. This is a truism to anyone who has been in school. Duhh! you say. I know. It's just a lot busier than I had imagined. Saturday is a perfect example. As an undergrad, you might write a paper for a few hours on saturday or do a little studying, but you generally had a good chunk of the day freee. Yesterday Aaron, Dan and I studied in the morning for nearly 5 hours. Our anatomy professor had compiled a review sheet with the weeks material in brief, and a list of review questions. We spent 4 1/2 hours going over it and we still hadnt' touched the last day's lecture by the end. I had promised mindy we would go and do something in the afternoon, so at 1330 we stopped and agreed to reconvene at 10pm in the anatomy lab. Mindy and I went to the world market to get some exotic cookies as a treat. This took far longer than we had anticipated because the highway is under construction. By 7pm I was back reading my old friends Netter and Moore. At 10, in the midst of a towering thunderstorm, Aaron, Dan, and I left to go take a practice practical exam in the lab. A lab practical is when there are different tags placed on the cadaver with a number and you have answer the questions regarding the tagged part. If it's a muscle, you might only have to ID the muscle, or just give the innervations, or the actions etc.. If it's a nerve, you might have to indicate what level of the spinal column it arises from and what kind of nerve fibers it contains. The ID"s are pretty straightforward, unless the cadaver looks like beef jerky, which was how we found them that evening. I did pretty well, I just made a lot of stupid mistakes which is usually the bane of my test taking. Got home at 1210, and went to bed.

Mediastinum and a long day

Yesterday we had our first embryology lecture. Here, embryology is taught once a week concurrent with the gross anatomy course. That means we have ten embryology classes, and one pass/fail final. Since we didn’t have gross yesterday, that meant no dissection and a little more time to study the dissections from the previous two days. Since the first lecture was pretty superficial and ‘big picture’, the locker room consensus was that it wasn’t worth our time to study embryology until we got some more detail. I’m inclined to agree with this assesment, since time is precious and embryology isn’t a big portion of the course. “ But you’re in medical school to learn all you can!” I hear you cry. So I am, but I study between 6-10 hours a day just trying to master gross anatomy without tossing embrology into the mix. If I had the time, I would study it every week, since it would actually facitlate the understanding of why certain structures are posistioned where they are in the body.
Regarding pace: We have about 90-120 minutes of lecture a day for gross anatomy. I asked my friends who took gross as undergrads what the pace was like with respect to their previous experience. It turns out we cover in one lecture what took them a week to cover before. That means we’re going about 5 times as fast as an undergrad. This is why I study so long. It’s exhilirating in a way, but I also know that it’s like riding a bike at 20 miles an hour along the top of a median barrier. It’s a rush, but there isn’t a lot of margin for error. If I miss just a little, the consequences are dire. THe material is pretty cumulative, so you need the previous day’s lecture to understand today’s lecture.
Today was just such a day. It wasn’t my turn to dissect (we rotate dissectors every day), so I studied for a few hours after lecture until the lab opened up to the rest of us. Our dissection for the day was the mediastinum and the pleural cavity. These lie directly below the ribcage, and include the heart, lungs and associated structures between the diaphragm and the clavicle. Our individual is rich in adipose tissue which really slows down a dissection because it has to be removed before you can actually see anything. The lungs weren’t in very good shape at the time of death, and the dissection process hadn’t aided matters. Everything was still really jumbled together when I got to the lab, so it was pretty tough to learn from the cadaver. The fact that I couldn’t see firsthand what I had been studying for a few hours set me back in my schedule quite a ways. I felt pretty panicky and behind as I left the lab frustrated and annoyed. A friend of mine who is a pretty talented dissector and has been helping me through anatomy offered to come in early before class and help me to see everything on his cadaver. Tomorrow morning at 6:45 we’re going to go over the mediastinum and everything else in there before lecture....

Spinous Process

Spinous Process
So we dissected yesterday. It was not a shocking as I thought it would be. Currently we are covering the back muscles, spinal cord, nerves, etc... Monday morning we were introduced to our cadavers prior to the first anatomy lecture. They were in blue tarpaulin bags with a zipper up the top. We unzipped our bags to inspect the cadaver itself for any scars, tattoos, missing parts (e.g. fingers). The faces are covered with a rag, they’ll be uncovered later. The body itself was pale yellow-white with gray parts too. I found that the hardest thing to look at were the hands, actually; I don’t know why. After lecture 3 of the 7 of us returned to the lab to dissect. The bodies were prone and propped on blocks to facilitate the dissection.
Our first task was to skin the back so we could probe deep into the muscles. Human skin is much tougher than I realized, it took much more force to pierce it with a scalpel than I had imagined. In life our cadaver was a hefty individual, lots of fat to pick away. Fat really blunts your scalpel blades, since you have to cut a lot of it away to reach muscle. The muscle itself of course did not look like it does in Netter’s Anatomy. It’s dark brown, kind of grayish too. The fascia that invests (covers and surrounds) the superficial and deep muscles of the back is a lot like strapping tape. It’s thin and extremely tough with whitish striations running longitudinally down it. We were able to distinguish and expose most of the muscles of the back, with the exception of much of the levator scapulae (raises the shoulder, kind of on the side and back of your neck), and some of the smaller muscles that turn the head. They overlap and aren’t clearly delineated in the body so distinguishing between the different muscles took professional assistance.
I think that studying for this class is going to mean a lot of time in the lab. The atlases are ok for getting a rough idea of what to look for and they’re invaluable in identifying stuff in the lab itself, but it’s hard to get a 3D mental image from book study alone. The most difficult thing about anatomy so far has been learning the innervation of the back muscles. The pace is really fast, I imagine that in the last two days, we’ve covered what would take a week at an undergrad school. At times the fast pace is terrifying, because I know that if I fall behind, I’ll never catch up. Since I’ve never studied innervation or anything remotely close, I have to teach myself the language in order to understand the texts and atlases. Yesterday I was in school or studying from 6am until 10 pm, with about a 90 minute dinner break. Long Day!

Poised on the Verge

So, I write this on the eve of my first day of medical school. On thursday we received our syllabuses for gross anatomy. The syllabus itself is a packet nearly two inches thick with outlines for every lecture. There was an accompanying packet filled with cross-sectional diagrams of each unit we’re covering. The first unit is the back, from the nape of the neck to the iliac crest.
Friday I bought my Netter’s Anatomy Atlas which is filled with pictures and labels, but no other text. I have an old edition of Moore’s Clinical Anatomy to supplement. Hopefully between the two of these I can make some sense of gross anatomy. Netter’s set me back $75, but at least it’s a nice book. The biochem book I bought during under grad was $130, and I only used it twice, which is why I still have it. Perhaps Voet and Voet will be more helpful in medical school than they were in under grad.
Friday and Saturday I studied the first unit, trying to get a handle on the language of anatomy and at least a superficial understanding of where the various muscles of the back are located. Moore’s is hard to read because it uses words like “inferolateral”, which I think to the layman would mean “down low and to the side.”
I’m pretty worried about the workload that I’m getting myself into with school. It’s been over a year since I’ve had to study every day, and that was for organic chemistry. With o-chem, I knew that if I put in about 2-3 hours a day I would be ok. For anatomy, I think, at least judging by my preliminary attempts to learn the back, the time investment will be something more on the order of 5-6 hours. The last time I had a workload that was similar was during the e term I was writing my thesis for history. During that quarter, I remember that pretty much every free minute was spent in the library writing or doing research. There were many times that I felt that I didn’t have time to go to class because I was too busy studying. Since I was pretty depressed during that time, I’m more than a little concerned about what is going to happen during medical school.
Being on the edge of this impending besogne I am reminded a little of the feelings I would have in high school when I was rowing. Every afternoon during the winter months I would get nauseous with anxiety when I thought about the upcoming erg workout. I couldn’t think about anything but how much it was going to hurt and how badly I wanted to do anything but row, a fear which was exacerbated by the knowledge I couldn’t get out of it. I know intellectually that medical school is going to be hard, but like when I was rowing, I also know that I can’t realistically get out of it, nor, deep down, do I want to. It’s going to be important to remember that there will occasionally be fun times and rewarding times interspersed with the hours of studying.
A vaincre sans périle, on triomphe sans gloire-Corneille. He did actually write something worthwhile!

Recap

Here is a brief recapitulation of our lives since we left Eugene.
-Spent 3 weeks at camp: wonderful time kayaking, reading and just hanging out.
Arrived in St Louis 2 weeks ago. We arrived at about 1130 in the morning, left our stuff at my grandma Flatley's in Kirkwood, and left to visit apartments at the Hampton Gardens. These apartments are in "The Hill", which is a heavily Italian neighborhood in west St. Louis. They were close to a heavily trafficked road which didn't really appeal. The price was about right, however. The primary downsides were: small kitchen (comically small stoves), smallish floorplan, and inability to place a piano on the premises. There was a basement which we could store things in, however.
After Hampton Gardens, we saw some rather seedy places in teh Central West End, which is close to Washington University, which is a few miles due north of the Hill. From there we went a little further into the Central West End, visiting Forest Station Ap'ts. These were ok, in old buildings that could have been nice. The problem was that, rather than preserving the oldness and capitalizing on it, the managers were trying to modernize the place on the cheap. The end result was an odd mixture of inexpensive low quality modern fixtures and carpet in old high ceiling rooms. The mélange of the two was poorly executed. We spent the next two days looking at more of same, growing increasingly frustrated. Everywhere was either nice but too expensive, or affordable but crummy.
Finally we decided to drive around Tower Grove Park, which is just southwest of the medical school and look for 'For Rent' signs. Along Arsenal, the southern border of the Park, we found a lot of rentals available. We finally got in one to look around and fell in love with it. Our current abode has pale green walls with white trim, wood floors, and old ceramic fireplace, built in bookshelves, a big kitchen with pantry, a bathroom where the tub has little legs, and a huge bedroom. The price tag was well within our range and best of all, the place was available!
To abreviate the narrative, we obtained parking permits from the police, had the truck delivered, and unloaded it with the assistance of the young men in our ward. 3 days later, we were pretty much unpacked and situated, with only the pictures and some other odds and ends left unplaced. The only casualties of the move were our kitchen table which was wounded in action (a minor gouge on the surface), and the box with our posters which disappeared entirely. I guess some thief somewhere is enjoying a collection of obscure prints from the Louvre. I hope he likes pictures of Egyptian artifacts and Spanish naval vessels.
All of these events bring us to the beginning of Orientation which will be sumarized in the next post.