Another week down

This week was something of a drag. I spent a lot of time in the lab trying to analyze my data, but without significant result. Reading mass spec peaks is hard and takes a lot of time, I learned. Even once I've identified what things are, the "so what" question remains frustratingly unanswered. Before medschool I always figured I didn't want to spend my life as a researcher, and I'm beginning to confirm that. I haven't written much recently, mainly because nothing of interest has occured. We're moving on saturday, which hardly seems real. I haven't really thought about our new place very much, so the moving date kind of crept up on me. The only reason we're moving is so that we can have another bedroom when young Grwn arrives . I'm surprised that Jefferson was as popular a name on the poll as it was.

The Learning Curve

(Editor's note: this is was written a week before it was posted for editorial reasons)

This was an interesting week. First, loyal readers will be delighted to know that I am penning this missive from a new MacBook.

So, this week I felt incompetent. In the lab I was trying to do stuff on my own so that I could learn as much as possible, but when you walk by yourself, you can trip. I did just that. Two days this week were true blunderfests. It seems that there's a threshold error level, above which errors tend to accumulate more rapidly. That happened with my neutral lipid samples. Without delving into the gory details, I managed to mis-transfer about half of my samples at one time or another. Rather than having nice vials containing only triglyceride or fatty acid, I now have a nice mixture, exactly what I was hoping to avoid. Yesterday, before acid methanolyzing my samples, I managed to contaminate two reagent bottles. Then, flustered, I also forgot to remove the chloroform from my samples before adding the acid methanol. I don't actually think there was a long term effect to this, but it made me feel dumb. We'll see tomorrow if they turned out.

After bumbling around the lab, Mindy and I went over to our friends Dan and Maggie to eat dinner and help them with their house. The girls left together to get paint while Dan, Rich, and I worked on the kitchen. Dan and Rich are rather deft with their hands, while yours truly is not. Obviously this is not some innate capacity, but of course skills learned by practice. I just have never been taught how to hang a door for instance. So, I stood around foolishly until Dan and I figured out something I could do that didn't require too much skill. Combined with the morning's mistakes in the lab, I felt pretty incompetant by the late evening.

Epilogue: The specimens didn't turn out too well, though not strictly because of my blunders. The purification method we were using wasn't high enough yield, so we have gone with another route for purifying the lipids. The TLC extractions weren't working because the lipids would oxidize in the atmosphere while the plates were drying. Consequently we are going to use HPLC in order to purify the lipids for use on the GC. In english, this means we are going to use a machine to purify the lipids rather than using glorified sand covered glass.

Nailing down a topic

This weeks has been a relaxing, occupied week. Compared with school, it's downright slack, but at least I have something to do during the day that isn't just time-wasting. I've alluded in the past to what I'm doing this summer, and now I know. I have to give a 10 minute talk (with flannelboard) about what I'm doing, so I'll give the loyal readers a sneak peak. Medical posts were not very highly ranked on the ol' survey-o-meter, so I'll try to keep this non-technical.

The liver, or as the French would say "le foi" (not to be confused with "la foi" - faith, a common missionary blunder) is the center of our focus. The liver metabolizes the fats and carbohydrates we eat. Excess of either are stored as triglyceride, which can simply be thought of as fat. What we're looking at mice who live on a diet rich in trans fat and high fructose corn syrup. Trans fats are not found in nature in very high quantities. They are made in the gut of ruminants, but not in great amounts. Trans fats are a by-product of the hydrogenation of natural oils, often soybean oil. Natural fats have reactive carbon bonds in them which can lead to rancidification, unless the bonds are modified. This modification involves heating and bubbling hydrogen into the oil to remove some of the double bonds. In the process, the orientation of the bonds is changed from a curved to a straight orientation. Saturated fats are fats from whom all of the double bonds have been removed, rendering the final product stiff like lard. Unsaturated fats have a few remaining double bonds, and are consequently more fluid and malleable.

Why should this organic chemistry affect you? Trans fat intake is associated with significantly higher risks of cardiovascular disease, as shown in several large epidemiological studies. It also has some disturbing effects on the liver, which is what we're studying. Our mice live a small, mousey, American life. They can eat all they want (known as feeding ad libitum), their diet is rich in trans fats, and their water is filled with high fructose corn syrup, so that they drink the equivalent of 8 cans of soda a day. We also remove the portions of their cage that they can climb on, rendering them much more sedentary.

When you examine the liver of the mouse (post mortem naturally), it shows changes known as steatosis, which means simply that lipids are accumulating in the liver. This occurs in humans too, in the context of obesity, alcoholism, diabetes, and also in cases of poisoning by certain toxins (CCl4 for the really curious). Steatosis is largely reversible, if the instigating stimulus is removed, i.e. diet modification or cessation of alcohol. If prolonged however, the accumulating fat kills the liver cells and causes inflammation, or steatohepatitis (fatty hepatitis). The inflammatory process can lead to fibrosis (scarring) which in the liver is known as cirrhosis. Most people associate liver cirrhosis with alcoholism, but it can occur just as easily in the context of excess lipid accumulation. In fact, under the microscope, cirrhosis looks the same, regardless of what caused it. Once the liver is cirrhosed, it no longer functions and needs to be replaced, either by transplant or resurrection.

When you look at the microscopic images of these fatty livers, the cells are filled with little droplets of lipid. Normally the body can mobilize stored lipids for energy, as in the case of prolonged fasting. Trans fats change that somehow, and we're hoping to clarify how. What I'm going to be determining is where in the cell the trans fats wind up. Are they stored in membranes? in the lipid droplet? This can be determined by analyzing the various classes of lipids and discerning which ones are enriched for trans fats (which, you recall, aren't there naturally). Once we know where they are, we can begin to postulate mechanisms for how they change lipid trafficking. Hopefully you could follow along with me, and if you're curious, I can give you the more detailed version via email.

Non-pharmaceutical Emetic

There's a sufficiently medical title. What you are about to witness is, quite simply, nauseating. I gagged, and Mindy, delicate flower that she is, soiled our rug. Those of you well acquainted with Dave Barry's Book of Bad Songs are undoubtedly familiar with this gem. To the uninitiated, however, hold on to your lunches because, without hyperbole, this is the worst song ever written. Both singers are clearly under the influence of some of 1976's finest illicit drugs, if you look closely. Behold:

NB: some browsers don't display the video properly. You might find you have to scroll down a little for the video to appear.

The Tender Mercies

As a kid, I would was taught in Primary that you should pray before a test, and the Spirit would help you remember the things you studied. I was always puzzled though, and wondered, 'well, if I'm studying, aren't I simply going to remember what I studied anyway? how does the Spirit actually help?'. As I grew more spiritually sophisticated on my mission, I realized that often times, the act of studying itself is what is needed, and that occasionally the Spirit would tell you things that you know you had never studied before, because you had prepared yourself by studying. I can recall an example of this from anatomy in the fall. It was a practical exam where things are tagged on cadavers and you have identify them. There was a hyoid bone sitting on a stool with a little tag that said "how many muscles attach to me?" I had never actually memorized the number, but into my head popped the exact number. I wrote it down, hoping it was right, but then tried to scribble all of the muscles that I knew attached to the hyoid in hopes of hedging my bet and getting partial credit. It later turned out that the number I had scrawled down was correct. I had always imagined this was the type of inspiration that the Spirit was supposed to give, but it never seemed to happen to me.

Today I learned another mechanism by which the Spirit helps us to learn. I had exactly one and a half days to prepare for the pathology final, which was cumulative. I spent 9 hours wednesday afternoon, and 13.5 hours yesterday cramming. Yesterday was the most focussed I have been all year, my mind was definitely in high gear . This morning I got up at 6 and reviewed cases online hoping to glean some gem that would be on the exam. I was reviewing pediatric neoplasia (tumors) and one of the pages had a chart delineating which tumors are common at which ages. Ewing's sarcoma caught my eye, and I happened to glance up and see that it was common in kids 5-9 years old. We have never discussed Ewing's in class, never mentioned it, I don't know what kind of cancer it is even. But, on the exam, there was a question "which one of the following would you most likely find in a 7 year old child ?" I checked Ewing's. I realize now, thinking back on the questions that Dan and Aaron and I asked each other while studying, that many of those questions were nearly verbatim test questions. Also, things that caught my attention for a brief moment before I moved on proved to be testable points. Reflecting on my childhood misunderstanding of inspiration, I realize now that many times, the Spirit is directing me what to study, so that I can remember it, rather than whispering the answer into my ear (though, as I showed, this does happen too).

Last Day of First Year

George is currently taking his final exam of the first year! I can't believe that this day is here! It seems like we just moved here, and that school just started, and that he cannot possibly be 1/4 of the way done with medical school already. This year has gone by so quickly, with the exception of the first three months that seemed to drag on forever while George was taking anatomy, and while I was not comfortable enough with anything here to feel remotely "at home". It is better now. George seems more comfortable with school and with the workload. He doesn't seem to get as stressed out about exams, and he really seems to be enjoying what he is doing...if it's not a test week. I am happier because my husband is happy. I have some friends now, and I have a bit of a routine. I still desperately miss the West: our family and friends, the mountains, the coast, stunning nature within minutes of my front door. Sigh.

However, I do feel more at home here. We came to medical school together knowing it would be hard work, hoping things would work out, and also having many misgivings about how life would be for us here. We happened to end up in a place where there are many young couples in exactly our situation, a place where we have many people to be good friends with, and for that I am eternally grateful. This whole experience would be infinitely more difficult if it weren't for my little support system of George's classmates' wives. We can be each other's families while our real families are all hundreds of miles away, and we can keep each other company while our husbands are working hard and are otherwise unavailable to us.

For example, this test George is currently slaving through is an accumulative Pathology exam. He took a Pharmacology exam two days ago, and he has been studying for weeks to cram the vast quantity of information into his head. Absolutely brutal! Test weeks are difficult because there is so much studying to do. I know it is more difficult for George than for me because he is the one actually having to put in all the work. I'm grateful that George is a hard-worker, but I get a bit stir-crazy when I haven't talked to him in days. So while he was studying last night, I went out with my good friends, Maggie & Bonnie. We got out of our houses and wandered around Target. It sounds like such a boring thing to do, but it was fabulous! I love my friends here, and I honestly don't know what I would do without them.

I am excited to spend some time with my husband after this test is over. And he is excited to sleep and to do non-medically-related things. I think a picnic and a trip to the park are in order today, if the weather allows it. And then we have eleven weeks of glorious, glorious Summer! George will still be working, but I'm counting on my assumption that there will be no late-night homework, no weekend studying, and no test weeks!

A most profound dullness

It's exam week again. The pharm exam is tomorrow, path is on friday. I have been cramming pharm since last wednesday, and continuing tonight. Total study time since last wed: more than a normal workweek's hours. Sunday was a day off. I''m exhausted, but I still have to study path. I have barely touched it since last week, and that's the exam that's cumulative. The profound dullness is my mind. Flat, out of gas, and tired. Time for bed so I can hit the books before the exam one last time. Will I pass? no question. Anything special? hmm. we'll see.



image from: http://a.abcnews.com/images/Politics/drowsy_2_080228_ms.jpg

Why write?

When the muse whispers, you must write. This is the thought I had as I was brushing my teeth a moment ago. Why must I write? The act of writing at once places the writer into history. I rekindled my love for history and literature again tonight. Mindy and I had just finished the final episode of The Office. Television is not a literary art form, by definition. It is an explicit medium simply because every image is shown explicitly and each viewer sees exactly the same thing. What they feel may vary, but everyone has seen the same thing. The beauty of literature, however, is that everyone imagines Tolkein's Middle Earth to be someplace else. My Narnia looks different than your Narnia, and Ramona and Beezus don't look the same to you as they do to me. I love the infinite variety of writing. Admittedly, I also like the quick fix entertainment afforded by television's omni-directional sludge pump - to steal a phrase from the Simpson's Side Show Bob.

While brushing my teeth I was thinking about some of the Balzac novels I read as a french major, and the 19th century France they portrayed. Balzac did not follow the conventions of contemporary story telling, where the audience is lead down a path by brute force and coerced into feeling prescribed emotions. The essential element of American popular narratives was also missing- the happy ending. Balzac described a time period in his character's lives, simply as a kind of decade long snapshot, without necessarily resolving everything, just simply to illustrate humanity. This blog serves, in its crude way, as a Balzacien glimpse into our world. I retitled it "Another Day in the Crucible" a few months ago in order to emphasize that this rather intense experience is a profoundly changing one.

I never realized, for instance, how long and hard I really could work and remain sane. I know how to study better than I ever have. I have learned, forgotten, relearned, and half-remembered an impressive collection of knowledge. I am more assertive in seeking knowledge. I learn now not just for exams, but for future utility. Personally, I am now coming to terms with becoming a father to a little boy in October. The thought is flooring, exciting, terrifying, all at once. I think I write to remain sane and to mimic real writers, so that one day I can pass this public journal on to my kids and say "look what Daddy learned and did in school".
-Spaceman Spiff

The Great Naming Contest

Now that we're in the 21st century, we don't have to rely solely on our own ideas of child naming. Instead, we have opened the floor to all you denizens of cyperspace to name our child. Here's how it will work: each week I will propose several names for you to vote on. At the the end of each month, there will be a vote off from the winners of each week. At the end of every trimester, there will be a vote-off from every month's winner. Finally, the trimester winners will be tallied and voted upon to decide the final name. In the event of a tie, the most popular two names will be used, in alphabetical order, as first and middle names. Use the surveys on the right of the page to vote!

Survey says:

Well, it looks like the readers have voted, and the consensus is that I should share more about what I do, and so should Mindy. Sadly, I don't have a lot of leisure activities. I did, however, play racquetball with my friend Dan this morning. I acquitted myself rather well, though I did lose every game. At least I kept the score reasonably close, and for a brief moment, was actually in the lead at one point. Dan has a wicked serve that is nearly un-returnable, but I managed to slap it back a few times. We had a very brief day of school, only 1 hr of path lab. I wasn't feeling great though, so I came home at 3 ish and crashed for the afternoon. Having taken microbiology and pathology, I can now understand in intimate detail how and why my nose runs, and why the phenylephrine I take to relieve it works. That doesn't do me any good though, because my teeth still hurt and I'm still really warm.

Other leisure activities. I went for a bona fide ride on Saturday. Aaron Y, some other guys from my ward and I all went for a ride out in the country. A real ride! It's been almost a year. We had to drive for about a half hour to get out of St Louis but it was a nice rural road with some nice bucolic scenery. Riding is so cathartic for me, it just helps me to relax and just 'flow' to use the pop-psychology term. I'm a lot slower than I was before, but I still enjoy cranking the pedals and flying along. I should do it more often. I really should, especially since it's good for me.

Spring Morning in the Park

It is a beautiful Spring morning.  It's also a Saturday and the first day since we moved from Oregon that George has gone out on a bike ride with cycling buddies.  I also had a first today; I ventured out on a run by myself for the first time since we moved here.  As per my husband's safety request, I waited to go out until late morning so it would be light out and there would be more people around.  And here's what I saw at 9:00 am:  I saw a 5K Fun Run with about 1000 runners (including young, spunky and healthy school children) and other people volunteering and organizing.  I saw some sort of street fair with tents and booths.  I saw a group of people doing Tai Chi.  I saw another group of people bird watching, with binoculars in hand.  I saw people setting up for picnics in the pavilions.  I saw the Palm House setting up for what looked like a wedding.  I saw parents taking their kids to the park playgrounds.  I also saw countless people out walking dogs and other people jogging...just like me.

Now, this is not a normal day in the park.  I have been out running with George and other partners many times, usually earlier in the morning.  We are usually one group out of perhaps five that we see out jogging or walking dogs.  I know I won't usually have this type of people-watching experience while I run.  But really, what a great day to enjoy some exercise, some fresh air, and a little of what this city has to offer.

I guess I have had another first today.  It's the first time I have felt inspired to contribute to our little family's blog.  My Spring morning in the park was really that enjoyable.

Intubation Lab

So I just finished a really cool after school lab with the anesthesia interest group. We were down in the sim lab and learned how to intubate. A third year resident showed us how to use the bag valve mask and then how to intubate. We split off into groups and practiced intubating on dummies, then on each other. No, I'm just kidding. We were only practicing on dummies. The laryngoscope is basically an "L" shaped instrument with a light pointing down the short part of the 'L'. There are two types, the Miller and the Macintosh, which vary in the degree of curvature of the blade (short part of the 'L'). We were using Macs since that's what works with the dummies. So, with a Mac blade here's how you intubate: Holding the scope in your left hand, you sweep the patient's tongue out of the way, inserting from the right and sweeping left. You then pull the scope upwards and away, at about a 45º. The end of the blade should be in the valecula. This should expose the vocal cords, which are your target. Once you can see the cords, you take your endotracheal tube which has a stylet in it for rigity, and attempt to place the tube between the cords and into the trachea. The tube should be positioned about 7cm above the carina (where the trachea branches into the two main bronchi). Then you inflate the balloon at the end with about 10cc of air and withdraw the stylet. The patient is then ready for ventilation! It was a lot of fun to actually do something clinical with my hands, as opposed to studying the side effects of chemotherapy drugs, which is what I'll get to do tonight.

An exercise in futility?

The other day in toxicology the professor recounted a trivial anecdote (or should I say antidote, considering the circumstances?) which seems to encapsulate a central dilemma in health care. 3 guys drive up to the ED and drop one of their buddies out at the door before speeding off. The guy was whacked out on heroin, emaciated, and incoherent. The ED doc pushes some naloxone (Narcan™) which is a reversal agent for opiates. It acts by competing for the same receptors as the opioid, and winning the competition. Since the heroin can't bind the receptor, no response is iniated and the addict's high is prematurely terminated. It also suppresses other effects of opioids aside from the high, depressed respiration for instance. The guy gets better and leaves, presumably to go shoot up and continue to ruin his life.

The episode raises several ethical questions which delineate some of the problems with US healthcare. What good did the doctor's intervention do? Yes, he saved the guy's life, but to what end? Should the doctor be legally required to help the guy? Should he have treated the guy in the first place, given that by treating him, he would likely be perpetuating a pattern of illegal behavior?

*editor's note: I deleted the rest of this post because it didn't say what I wanted it to.

Final 4

No, it's not the last four teams in the NCAA basketball championship. It's the last 4 weeks of school! I had a pharm exam on friday and a path exam on saturday. Both went well, the grades are already back, surprisingly. I did quite well on path which was a pleasant surprise since I had studied pharm far more. I'm going to have to bust my butt on the next exam to do as well as I'd like to in pharm. So far, I think that I can say that medical school isn't too bad. I study a lot, last week put in about 60 hours before the exam, but overall, it's not bad. I can't believe that in a few weeks I can consider myself an MSII. I don't have much else to write. Mindy and I are finding out in two weeks if we're going to have a Dayshawn or a LaFonda.

To potentiate or to antagonize, that is the question

A few things are new: first, we are getting a new bed. The current bed has gotten so bad that I spent last night on the floor in a sleeping bag. I would liken it to sleeping in a ladle. Your spine is bent laterally along its longitudinal axis, and also the anterior/posterior axis. If you lie on your back, your sacrum slowly drifts down so you have a nice anteriorly rotated pelvis. This, combined with my year old running shoes means that I live with constant back pain. Having slept a grand total of 5 (ish) hours Sunday evening, I said enough's enough, and moved to the floor where I slept soundly all last night.

To rectify this crappiness, Mindy and I bought a new mattress today. Hopefully this one will last through residency. I have been sleeping like the happy fellow above, and I'm tired of it.


On a more medical note, path and pharm are a lethal combination. There's just so much testable material! We're covering ANS (autonomic nervous system) agents right now, which will be useful if I go into anesthesia. This week we covered muscarinic agonists, antagonists, and acetylcholinesterase inhibitors. We're also covering the α and β agonists, antagonists, and re-uptake inhibitors. Perhaps a brief exposition will clarify and edify:


The ANS is divided into two main branches that govern all of our subconcious bodily functions, including sweating, heart rate, vascular tone, digestive secretions, eye focusing, dilating and contraction, and to some extent the reproductive organs, as well as many others. These two branches are respectively, the sympathetic, and the parasympathetic. These are mainly anatomical terms, referring primarily to the site of origin for the respective nerves. The parasympathetic nervous system is mostly in charge of the "rest and digest" functions, e.g. secreting gastric juices, slowing heart rate, contracting the pupil, constricting bronchiolar smooth muscle (sound familiar all you asthmatics?). The sympathetic nervous system, on the other hand, is in charge of the "fight or flight" response that you associate with fright or stress. This means it increases heart rate, dilates the pupil, dilates the bronchioles, constricts the peripheral vasculature to raise blood pressure, reduces gastric motility, reduces gastric secretions, etc. Still with me? Good.

The two systems also differ in the neurotransmitter secreted at the synapse or junction. The sympathetics release norepinephrine (mostly) and the parasympathetics release acetylcholine. What about adrenaline (which is epinephrine in the US)? It is mainly released by sympathetic stimulation of the adrenal medulla, a wee gland perched on your kidney. These chemicals elicit the effects described previously.

Once the transmitter has been released, it acts on a receptor, which is a molecule that protrudes from the cell membrane. When the transmitter binds the receptor, the receptor modifies other molecules inside the cell and elicits the appropriate response (e.g. secretion or contraction of muscle). Sympathetic drugs stimulate α and β receptors, while parasympathetic drugs stimulate muscarinic and nicotinic receptors (it's a little more complex, but this will suffice).

The real fun begins when you consider the multiple ways to antagonize or potentiate the effects of endogenous neurotransmitters. You can irreversibly inhibit a receptor which means you chemically modify it so it no longer recognizes acetylcholine or norepi. You can competitively inhibit it which means that Ach (acetylcholine) or NE (norepi) have to fight for a spot to bind with the drug. These facts are pretty straight forward though, in comparison with the real meat of the course

When it gets really interesting is when you start considering multiple drugs. What happens to heart rate and blood pressure if you agonize muscarinic receptors, while simultaneously blocking alpha receptors? What's going to happen in the GI if you do this? is the patient going to crap themselves because you overstimulated the parasympathetics?

Ahh fun.



Answer: (as I can figure it out): muscaranic agonization: slow HR due to Ach on M receptor. Increased GI motility. Alpha block prevents baroreflex from stimulating α1 vasoconstriction, so BP stays lower than normal. Also decreases sympathetic tone in GI, allowing paras to dominate. Not sure when you would want the patient hypotensive and bradycardic, but there you have it. Wow. look ma! I larned something!

Slogging along a Path(ology)

(left: Arachidonic acid molecule)

The title is something of a misnomer. Pathology is actually a great class. It uses thing from pharm, micro, and cell bio. This means that I have to dredge up memories from cell bio of things I haven't seen in maybe 6 months. Path is, to use the current pedagogical buzzword, "integrative." We have lecture only once a week, and then gross lab for 90 minutes once a week, and another small group activity for another 90 minutes. This small group activity is far superior to the organized dawdling that was genetics PBL. First, these groups are self-selected, so I only work with people I know work hard. Second, there is not moderator to dampen any collaboration. The moderators in genetics, just by being present and having control of our grades were likely, even without any effort or outward expression, to quell a lot of the error prone dialogue which makes this kind of exercise educational. The absence of a moderator permits us to explore freely and make mistakes, but also to learn faster because we can be wrong and learn from it. The book is a ponderous compendium, but nevertheless a great resource.

In other news, it looks like my summer research project is going to be funded. Do I fully know what I'm going to be doing? hmmm not really. At least they'll pay me to do it though. This week I learned how (sort of) to do a protein assay. The project I'm currently working on is comparing the lipid content of mouse livers from a high fructose corn syrup (HFCS) and trans fat (TF) diet, vs. control of normal chow. In quantifying the lipids, we quantify them relative to themselves, i.e. what percentage of the fatty acids are arachidonic acid for instance. We also quantify them absolutely by comparing them to the protein content of the liver. Since fatty livers have varying amounts of water, using a dry weight/ wet weight comparison is not as accurate as simply using the absolute amount of protein present which is more or less invariate.

To do this, we extract the protein from the protein layer of a liver homogenate. The liver homogenate is basically ground up liver in a solvent, which is then centrifuged. Different cellular components sediment to different layers, which we can remove by pipette. The protein layer is removed and put into an aliquot. We put a known amount of protein into de-ionized water and run it on a spectroscope. The spectroscope bounces light off the protein, and quantifies the amount reflected. This number then is to give an amount of protein present in the sample that can then be compared with the lipid content. Still with me? basically, the process I just described is what I learned to do last week. I don't know that I could do it again by myself, but I would make a valiant stab at it.

Back to the track

I might have been a little premature in thinking that school was getting easier. Pharm is pretty tough right now. All of the kinetics (i.e. rates of absorption, excretion, etc.) stuff I thought I could safely leave in gen chem has come back to haunt me with a vengeance. I finally got my grades from Genetics and things went pretty well there after all. I've noticed in medical school I'm a lot more ambivalent about grades. As an undergrad, a 91 % on a test would send me into a depression for a week. Now, as long as I'm passing and doing a little better than average, I'm ok. I don't sweat failing, and, as the truism goes P= MD. I'm not slacking, but I don't really care as much about the grade, which is very freeing. Perhaps I've finally grown up. Unlikely. I'm still 13 on the inside, I just have good days when I act my age.

Last block

The last block began today. I'm now studying pharmacology and pathology. We have pharm a whopping 6 times a week to the paltry twice-weekly path sessions. I'm hoping I'll enjoy pharm since I want to do anesthesia which is all pharm. My friends give me a hard time because I always remember the drugs they tell us to ignore in all our other modules. I just got my gargantual Robbins pathology book in the mail today. Hopefully it will be more than a $90 doorstop, though who can say. The second years in my ward say they use it pretty frequently, so it seems like a good investment. I can't believe how fast the time has flown by. So far, it really hasn't been as bad as I though it would be. This block looks to be pretty tough because we have class most of the day several days a week. I don't really like that because I would rather have that time to study.

It's spring break, I guess.

It's always saturday afternoon. Any time I have a few consecutive hours off, it must be Saturday afternoon, which means tomorrow is Sunday, and that means church. Naturally, today is tuesday, so no church tomorrow, but it's still saturday afternoon. I think that friday afternoon, I will realize that I've just had spring break, and that it's time to go back.

My genetics exam didn't go as well as I had hoped, which was frustrating. It's the one class I've come closest to honoring this year and getting a negative z-score isn't the best way to finish the block. I was surprised that genetics wasn't really very hard. My undergrad class was a lot more molecular biology and not as many diseases, which made it more challenging. Virology was just tons of rote memorizing. Which viruses have +RNA genomes? which ones have ssDNA? circular DNA? reverse transcriptase? what could possibly be causing these symptoms: fever, nausea, vomiting and malaise? that's right, ANYTHING!

Well that's done. Onward to pharmacology and pathology for 9 weeks, then I'm done with first year! It has literally flown by. School has definitely gotten easier. I don't know if it's because last block I had already had genetics so the material was easier or I'm just better at studying, or if I have gotten used to the idea that no matter how hard I try, I can do no better than pass my classes?

This summer's plans are somewhat nebulous at the moment. I wrote earlier that I'm going to be researching perfused rat hearts and lipids? well, I might be doing something slightly different. The fellowship program that I'm applying for is only granted on a one student per lab basis, for reasons that were poorly explained. Unfortunately, there is one other med student already in my lab, which means that I have to find another PI. My current PI is collaborating with an MD on a project, so what will likely happen is that PI #2 will be 'in charge' of me, while I work with PI #1 in his lab. I don't really know if I'll be working the perfused heart, or if I will in fact be studying the effects of a fast food diet on mice livers instead. Hopefully I can do the heart because that's what really is more interesting.

Wow. Just wow.

So we had a standardized patient interview group meeting this week in PPS (patient physican and society). What we do is sit in a group, one of us interviews an actor playing the patient, we discuss possible diagnoses together, then someone else talks to patient about the diagnosis and possible treatments. This week's subject was diarrhea. The following story was related to me by my friend in whose group the following events transpired.

Our protagonist elicits the following history:
The patient is a 2 year old boy. His hispanic father relates the following history: patient has had watery diarrhea for the last 12 hours. The family had eaten together at a church picnic where chicken, warm rice, and other potluck foods were served. 5 hours later, the patient, and some of his family members all reported having intermittent non-bloody, non prurlent diarrhea.

Even the most un-medical lay person would probably leap to the diagnosis of food poisoning, specifically, some toxin mediated form (B.cereus, S. Aureus, or some other form). The history fits, the signs and symptoms fit, and the diagnosis is, in fact, food poisoning. You might also consider some viral gastroenteritis, but since the whole family is simultaneously sick in such short order, the illness is more suggestive of food poisoning. Now is when our hero shines.

When queried by the moderator about possible illnesses to include in the differential, our hero says:
"well, I feel that, it's , you know, like maybe esophageal atresia. Maybe it's like, like, a fistula, you know? like a tracheal-esophageal fistula? Or maybe, you know, I can't remember what it's called (now he waves his hand vaguely over the right upper quadrant of his abdomen), you know, like some hypertrophy of something? the duodenum? "
"Pyloric stenosis?" asks the moderator, dumfounded.
"yeah" replies the champion.
"NO." says the moderator, floored at the ignorance of our protagonist.

Now, some vocabulary for you so you can understand the colossal mistake that our protagonist made.

• Esophageal atresia: when the esophagus forms in the embryo, it initially forms as a solid structure which then hollows out. If the hollowing out is incomplete, you have esophageal atresia. In other words, the esophagus is a blind-end tube. The first meal that the baby attempts to take after birth would, of course, not reach the stomach. No way this would happen in a 2 year old. Most of all, this COULD NOT, by definition, cause diarrhea! (not to mention everyone in the family? simultaneously?)

• Tracheal-esophageal fistula: an aberrant connection between the trachea and the esophagus, again from an error during embryogenesis. Also, this would have been evident during the neonatal period. Again, not a cause of diarrhea.

• Pyloric stenosis: The scar on my abdomen attests to my experience with this. In this condition, the pylorus, which is the connection between stomach and the uppermost portion of the small intestine, closes due to overgrowth of the sphincter muscle found there. Typically, this presents in first born males in the first month or two of life. Characteristically, there is projectile vomiting. Since the GI is closed by the hypertrophied sphincter, of course no food is reaching the colon to become diarrhea.
  

I'm amazed at how wrong his diagnoses were. Come on! the conditions he described, for the most part, are obstructive and would not, could not, result in diarrhea!! Not to mention that common sense alone would tell you it's food poisoning (though you might have to have microbiology to tell which bug is the likely culprit.) This dude is one of the SLU medscholars, who were selected as college freshman for automatic entrance into medical school, as long as they kept their grades up in undergrad. Simply stunning.