Thursday, December 22, 2011

Take 2 of these and try and get a human on the line through my cold and uncaring automated call system in the morning

A couple of months ago I was talking with a professor at school about the pharmaceutical industry, and he mentioned that the Pfizer had recently lost $20 billion in valuation due to a new drug in trial phase III being shut down. This particular drug was going to be a follow up to Lipitor, in that it was a specific cholesterol drug, one that of course, should be taken for life. Here is a great article about not only the failure of the drug, but our misguided relationship of causation and correlation: link to worthwhile article. The author of this article has some very interesting points, and many of them tie in directly to things that I find myself contemplating quite often. The vehicle of reductionism in the realm of science has wrought answers by increasingly breaking down the physical world into smaller and smaller pieces and, admittedly has brought us to amazing places. Think of Star Trek. For the most part, Star Trek is based on a premise that technology will save us, and through the advancement of technology humans will become better people with a more benevolent society to boot. Many of the people in research are people who probably like Star Trek, and this is why we've reached this point of diminished returns in scientific advancements.

Of course, if you had read that article that I linked to you're probably saying, "wait a minute, the correlation of the concentration of Trekkies in fields of biotechnological research is not a causative element for the relative diminished returns in said field!" I can't pull anything past you guys. As a society we need to ask ourselves what kind of valuation we put on this type of research. Drug companies are finding themselves in a position that where they can not justify continuing this research. As is mentioned in the article, a couple of the largest pharmaceutical companies are discontinuing research in brain related therapeutics, because the darn thing is just too complicated. One has to wonder what important, quality of life improving drugs will be left undiscovered simply due to financial risk and/or limited payoff and benefit to shareholders.

As is the case in so many other areas of healthcare (indeed, our increasing capitalization of everything in society) we must come to a place where profit is in balance with overall societal benefits.

I can become discouraged when thinking about these seemingly insurmountable larger issues. But, then there are times when I'm reminded what kind of impact I can have, as a doctor, especially as a D.O. Learning how to treat people with my hands, to reduce people's immediate pain with tried and true manipulative treatment is a lesson in the power of non-reductionist means of treatment modalities. I don't mean that there hasn't or won't be research into OMM, but for the most part, the techniques that we have been taught feel good. Massage therapy feels good too, right? Yes, of course, and I might argue that patients with any number of ailments would benefit from a session with a masseuse. However, being a physician provides for the best of both worlds, in that many of the benefits that come from seeing a massage therapist are also gained from having a DO treat you with OMT. This is just the baseline benefit, however, in that laying hands on a person is therapeutic in and of itself, but having the knowledge of how to improve the function of the patient stemming from diagnostic criteria is in the realm of the physician. It may be as simple as recognizing that some lymphatic vessels need help draining, but the point is that it doesn't take $25 billion to figure out if this works or not. I feel obligated to say that, I am thankful for many of the agents that do take billions of dollars to develop, and they will be a major and sometimes inclusive part of how I treat patients, but in no way do I wish to be limited in my treatment options, in all situations, to these drugs.

I would not have known that lower back pain has been proven to have, in most cases, no correlation with lumbar spine abnormalities had I not read that article. Most people still talk about bulging discs and pinched nerves being the cause of lower back pain, when in fact it has been shown not to be the cause. I can only hope to appropriately navigate that future technologies that take us down the false causation path, but in many cases I will be following the guidelines set forth by knowledgeable people, but people nonetheless. I guess I can be happy that I'm not going to be practicing in the time when bleeding was proven to be a unhealthy (if not fatal, as in the case of George Washington) practice. Acceptance of the idea that I had done major harm to my patients while trying to bleed out the "bad blood" would be a difficult pill to swallow, hopefully I can, in some way, mitigate the pills that are akin to "bleeding" of the patient.

Saturday, December 17, 2011

Sorry LMA, my mind decompresses in strange ways.

The semester is complete. I don't even have to go back to school until 2012!

I had a dream last night in which LaMarcus Aldridge, an NBA basketball player for the Portland Trail Blazers passed away. It was nothing against LMA, but more the fact that I was catching up on the NBA news of the past 3 months before going to sleep. However, it wouldn't be all that surprising if something happened that kept Aldridge from playing this year; granted, he doesn't need to die or anything for that to occur.

Next semester we jump in to Cardiovascular/Respiration/Renal systems right away. I think I'm gonna start listening to the Goljan lectures a little early. I started listening to them at the end of last semester and not only found them helpful, but they were enjoyable to listen to. I suggest them to anyone who is in or hopes to be in med school. Viewing my peformance last semester, I find it interesting that in the practical side, where the grade is derived from "treating" and/or interacting with a "patient" (who thus far, with one exception has been a fellow student we were paired up with) my marks have consistently been significantly better than the "theory" examination grades. Last week we saw an actor who played the role of the patient as we gave them a timed physical examination. I just about earned a perfect score, and received positive feedback regarding my communication skills and interaction with the "patient." Now, we were actually supposed to exam this person, and report any irregularities but these were screened actors and any thing beyond a slight or minor deviation from the norm presenting was minimal. So, my good score was earned by memorizing the lines I was supposed to use to report back to the proctor and by being able to bury the nervousness and put on the smile and charm with the patient.

I think this skill to deal with people in stressful situations (usually -- there has been many times where I've lost it as well, as I'm sure many of you reading this could attest to) was honed by working in the ED. But, I think the foundation for it came from working customer service at a coffee shop/roaster. Granted, there were many days that I was thankful to spend my days roasting coffee instead of making it, I really enjoyed the customers who came in there, many of them regulars from before my 8 year career there. In fact, one of the influences that led to my choice to go to college came from the customers. The shop that I worked for was located a block or two from a good sized private university, and I think getting to know the different professors and students helped me realize that I really wanted to go to school, and for that, as a collective whole, I thank you, former customer.

Wednesday, December 7, 2011

No Steve Perry-oral cyanosis noted.

Today was my first exam performed on a stranger. Granted, the "patient" was a paid actor that the school brought in. It was the final practical for our doctoring course (which means 1 out of 4 final exams is out of the way!) and as always, is a timed, monitored exam. I've grown to like these practicals, as I think one of my strengths is being able to communicate and perform under pressure. The "patient" feedback included that I made her feel comfortable and that I seemed calm and confident, which was nice to hear. However, when I asked her what arm she preferred to have her blood pressure taken from, I proceeded to take it on the other arm, oopsy. But, that was the biggest mistake I made. If I do as well on all my other exams this will be a triumphant first semester indeed.

Wednesday, November 30, 2011

The Reichstag is burning

Today  in school we had one of our "balancing" classes, designed to remind us that we, by necessity must become imbalanced in order not to flunk out of med school. At least, that's what I take away from the classes. Nevertheless, there are usually some nuggets of wisdom to take home, and today provided a couple. The first one, I'll just briefly mention, is about a doctor who was diagnosed with terminal esophogeal cancer and, during this time gave lectures and wrote a book. It was only last spring he was in the lecture hall, kind of as a dead man walking, lecturing about the important things in life. The students who are now second year OMS's got this lecture, and I wish that we would get the same honor, but alas, he passed a few months ago.

The second half of the class we formed small groups and discussed how 9/11 affected us, what happened to us that day, etc. Of course, many of my fellow students were still in high-school back then and in a few short years this will no longer be a day that "everyone" remembers. I can remember growing up and people talking about the day Kennedy was shot, or the moon landing and even Pearl Harbor. Soon, I will be one of those people, talking about the day 9/11 hit. I know everyone has a story about that day, but, since this is my blog, I'll write mine down -- I wouldn't want to forget any of the details in my old age!

In 2001 I found myself in the first real, serious relationship that I had ever been in. We had purchased a house together in SE Portland, I was working with some friends as sub-contractors making decent money in the construction business. Needless to say, I had no intentions of going back to school, much less moving to Florida, where the girl I was seeing at the time was from. That summer she decided to return to grad school, and she wanted to attend a program in Tampa, FL. Long story short, I was to young and naive at the time to figure this out, but I don't think I was really invited to go along. I didn't let that stop me, however, and we packed up the Honda, with our two dogs and drove to Florida. The girl's father had a business acquaintance who owned a retail flooring company, and was kind enough basically to get me hired sight unseen. This was nice, and I appreciated it, but I soon found myself very unhappy working for someone else, as I had gotten used to basically being my own boss. Now, I was expected to show up at 6 AM sharp and take instruction from the Vietnam Vet who was the other installer that worked there. Awesome. Oh, and the fact I was taking a 75% cut in pay made for a very difficult pill to swallow. I was 22 years old at this time, and I'd like to think that I'd handle things much better these days, as I'm sure the Vietnam Vet nor the couple that owned the business were very thrilled with having me around, either.

I'd been working with this outfit for only a few days when 9/11 occurred. Our job that day was to replace glue down carpet in a mortgage brokerage company. Basically, it was one big room full of desks, with a few offices off to the side. We had to slide all the desks to one side of the room (I remember the Vietnam Vet making me unplug all the computers and phones, as he said he didn't want to mess that stuff up) basically making one big desk on one side, while we scraped the carpet off the concrete on the cleared side. Awesome work -- I can feel my lower back tense up just thinking about it. We'd been working for close to 2 hours when the boss burst out of the office, bringing her TV, on a rolling stand with her. Sure enough, a plane had flown into the WTC tower in NYC. We all watched, (well, I snuck peaks while my Vietnam Vet overlord told me to scrape faster) until the next plane hit. That's when people began to pay attention. I remember seeing it live, as the camera panned upwards as the plane screamed low over the buildings. Of course, not long after that there was the Pentagon incident and the Pennsylvania field crash. By 11 in the morning, I was still scraping carpet, but now the 20 or 30 ladies that were still left in the office were all sitting around this one, older lady who was standing on her desk, reading with a booming voice from the Bible. Of course, she was in the book of Revelation, describing bowls of wrath being poured out. Women were crying, weeping, shaking. I was scraping, wondering when I could go home.

A side note, one I had forgotten about until today when we were discussing how that day impacted us, has to do with the US's central command, which is in Tampa. I'm not sure if this is correct, but I remember people saying that all military air traffic was directed out of central command, and that if there were more attacks coming, this base, a dozen or so miles from where I lived was sure to be high on the list. The description of a nuclear weapon brought in on some kind of ship or submarine into Tampa Bay haunted for me for a bit. I, like most people, was just a tad bit more jumpy than usual in those proceeding weeks.

I've always been very skeptical. Of everything. I'm not sure you could call me a "truther" which is a name given to all those who say that 9/11 either was an inside job, or at least coordinated by our Government. However, I'm open to any and all evidence, from both sides. I've always enjoyed history (in fact, I'd love to be a history professor, but, alas . . .) and I wasn't the only one who soon began to think about the Reichstag incident that preceded the Nazi Party's rise to power in pre-war Germany. I really do believe that it is important to know know, or at least beware of the history of this sordid species, capable of great deceit and manipulation. Anyway, enough of that.

However, the reason I even bring this up, is that I was mildly and pleasantly surprised by my younger classmates today. Overwhelmingly they felt that 9/11 was used inappropriately. One person mentioned that, if he were old enough when 9/11 occurred that he would have joined the Marines, but now, with the benefit of a decade of failed military action in multiple places around the globe, all intimately initiated because of 9/11, he is thankful that he was 14 instead of 18. I really don't know what the real story is behind 9/11. I'm fairly sure it is not the one told on CNN, but that goes for everything. If anything, I felt like there was hope for the future, and that whoever it was, and whatever they were trying to accomplish by flying those planes into those buildings would not get what they want. Granted, the sample population was young medical students, so I'm not foolish enough to think this is indicative of the general population, but I'm thankful for people who are not so quick to buy whatever the mass media news outlets are selling.

Saturday, November 19, 2011

Is a Monte Cristo sandwich named for the delayed gastronomical revenge it will have?

During one of the first days of my time working in the ER we had a newborn brought in for phototherapy to help with it's hyperbilirubineremia. I really didn't know what this was, it kinda sounded familiar, but I knew next to nothing -- not even how to spell it. When registering patients, we would put in a brief description of what was going on, in this case my more experienced coworker told me to put in "bilirubin." What I wrote was "Billy reuben." Even though it was closer to breakfast, I'm always game for a Reuben sandwich, even if the rye bread is a little more yellow than it should be. 

Monday, November 14, 2011

Sorry bout dat e'rbody

Earlier this year I emailed Billy Hunter & Derek Fisher telling them that David Stern had called them some bad names. I also emailed David Stern to tell him that Billy & Derek had also called him naughty names. I did this so that there would be no NBA season and thereby eliminating the temptation to watch Blazer games instead of doing homework.

I'm glad to get this off my chest, as this is the first I've spoken about it. I would like to apologize, as I know it was a selfish move on my part, but I felt it was what I had to do.

Thursday, November 10, 2011

This post is at least PG-13. R if you live in the midwest.

This week we've had some really good lectures on HIV/AIDS. I'm old enough that I can remember the late 1980's which saw the near panic crescendo from all of this. Perhaps, the climax was Magic Johnson's diagnosis and retirement from the NBA. It is a little hard to believe that that was 20 years ago, as the anniversary was just a few days ago. I can actually remember thinking that this was good for the Portland Trail Blazers, since Magic's retirement left the Lakers in a bind. Of course, this was the thoughts of a young boy insulated from most harsh realities of the real world. All that surrounds the AIDS epidemic is so crazy and dramatic compared to most other areas of medicine. A friend whom I worked with a few years ago was getting a master's degree and in one of the classes she was taking the professor espoused the idea that the CIA had created HIV on purpose and distributed it to people in Africa, and this is where it came from. I really don't know much about that, I haven't read or talked to anyone who holds that position, but even for a person like me with a penchant for obscure conspiracy theories has considerable doubt concerning that one.

I grew up in a very conservative Christian community and I can remember in various youth groups we had some people holding the opinion that HIV/AIDS was a punishment from God, meant for homosexuals. In this same exact logic, one can conclude that diabetes, heart disease and any other random obesity associated disease is punishment for the fat people. Polio is punishment for people who liked to swim in public pools. I won't go off on this for long, but for those who want to prioritize sin (or what they perceive as a sin) had better reread what the good book says about that, as one is just as bad as another. I attended church in Benicia a few weeks ago and the pastor said something that really struck me. He talked about how, in the gospels, Jesus never once mentions homosexuality. However, greed and pride are discussed in a manner that leaves no doubt as to how he views them. How is that the many churches have nothing to say about the greed and pride that are abundant in our economic system but rail against homosexuality as if eradication of it was the prime-directive? Okay, sorry, I'm off the soap box now.

Back to a lighter topic, AIDS.

I remember an afternoon when I was working in the ER when we had a patient come in complaining of priapism, which is an erection that won't go away. He had this erection since the night before when he took a handful of viagra and another handful of various club drugs. This was literally how he was describing his prior night, he was at a dance club and he and his friends just kind of mixed whatever kind of drugs they had together and just ate 'em up. Ecstacy, MDMA, LSD, GHB, Ketamine -- you name it. Oh, and someone had a big bottle of Viagra, so they split those up as well. Let the party begin! This guy did this on a regular basis, but not with the Viagra so now, 15 hours after his weewee came to attention he was in considerable pain and came to see us.

Once the nurse found out it had been 15 hours she rushed him back to one of the rooms. One of the things I liked to do when I worked in the ER was kind of listen in or watch from a distance what the doctor was saying or doing. I think I learned a lot by doing this. If anyone out there is reading this and is thinking about applying to med school I can tell you that working in a clinical setting will provide so much more than an official "shadowing" afternoon will. Anyway, unfortunately the door to this patient's room was shut for the next few hours. But, thankfully some of the nurses were more than willing to give me the play-by-play. At first they tried to get the erection to go down with various drugs. I'm guessing NO was probably one of them (as it relaxes smooth muscle) but I really don't know what else, except that none of them worked. The rooster was still on the roof of the barn cock-a-doodle-a-dooing-away, and he wouldn't come down. Then the nurse told me, as he was gowning up and donning eye protection that the doctor was going to try and take the blood out with a needle, and that the patient was HIV positive, and that he was going to have to be in there as well to assist. I'm not sure what happened next except that when the doctor and nurse came out they were covered in blood. The bed and the floor in the room was soaked as well. I once had a friend that had another friend who worked as a photographer and as such, was in the visiting team's locker room at the Pepsi Center, where the Nuggets play. Supposedly when Shaq walked out of the shower, sans towel, the first thought that came to his mind was no way, a 2 liter bottle!? and, I'll just leave it at that. The reason I even bring this up is I have a feeling that this poor man might have been packing a RedBull can, at best, but you wouldn't know it from the blood that was everywhere. The room had to be thoroughly cleaned and sanitized, as is appropriate, after that.

So, that's what we're studying yesterday and today. And then on into other viral and bacterial infections.

Tuesday, November 8, 2011

Alexander the Grape, Johnny Apple treats and Cherry Clans don't tast as good as Apple/Cherry/Grape-heads.

This evening I made a run to the small market  a mile or two from our house. Seeing as how today was the last day of our block exam fiasco, and my knee is progressing to the point where I can nearly bend it without blinding pain, I figured it was important to pick up some laffy taffy and lemonheads. While in the market the lady who owns the place, whom I've gotten to know, asked me about my still prominent limp. I started to tell her about the whole experience of being diagnosed with gout and how bad it was and that the timing was about as unfortunate as it can get and all. In the line behind me was a younger guy, could have easily been me from 7 or 10 years ago who chimes in and tells me that doctors are just drug pushers who are no better than a crack dealer. He says this with a sly grin, obviously having no idea that I was actually working my ass off to try and join the ranks of the "crack dealer." I just kind of half smiled, nodded and finished up my conversation with the nice shop owner, took my candy and started to limp away. The guy behind me set both of his 40oz Ole' English Charcoal filtered malt liquor bottles on the counter and also asked for some Swisher Sweets.

When I arrived back at my car, my 90lb dog (who I had brought along with me just to be nice) had dropped a couple turds in the back seat. I had to drive home with the literal and metaphorical smell of excrement all around me. This is not to say that I completely disagree with the Malt Liquor aficionado's accusations, however, the idea of hopeful crack dealers traveling the country and interviewing for a chance to actually disperse crack rock (after spending 4 years learning all the abstract, peripheral knowledge surrounding crack rock and then acing the CRCAT)) on the corner sums up my opinion of his opinion.

Sunday, November 6, 2011

If I was living like a King, perhaps I could understand why this is happening to me.

Since we moved to California from Colorado, I've had a couple of weird things happen with my joints. In fact, throughout my life there has been many issues. Dozens of dislocations, mostly of the shoulder, but also an elbow, patella and a couple fingers. The only surgery (besides wisdom teeth removal) was a shoulder reconstruction deemed necessary from all the dislocations. In July, before school started I came down with an attack of gout in my large toe of my right foot. I was drinking a few glasses of wine most nights, but other than that I really wasn't engaging in overt gout promoting behavior. It put me down for 3 or 4 days though. There have been a few other times where my knee would swell up, and since it correlated to a coldish, stormish front moving through I chalked it up to one more thing that confirms my old-fartness. Well, if I needed one more confirmatory episode I was handed a whopper over the last few days. I had another gout attack, except this time it was in my knee. And, again, I really had not engaged in overly suspect activities this past week. As I have been preparing for my exams I wasn't drinking alcohol at all and, if anything I had more cheese than I might normally, but it's not as if I ate a few pounds of the stuff. Today, the pain got to the point where I actually visited the emergency room.

I wasn't completely sure it was gout, but since there was not trauma to point to and no obvious paths of infection to cause what appeared to be a swollen, cellulitic knee I figured I should be seen. If nothing else I was going to need a doctor's note if I could not even move or walk for my practicals that are scheduled on Monday and Tuesday. The doctor in the ER did not identify gout right away, and said he really wasn't considering it until I told him about the attack I had in July. I guess I feel a little better about that, as that means he didn't see me as a prime gout patient, but on the other hand, why am I being struck with this horrible, utterly tortuous affliction? I even told my wife that if I could ward off another attack I would gladly give up all meats, fish and yes, even beer and wine. That is how bad a gout attack is.To think I thought the toe was painful, well, I learned my lesson and now know that the knee trumps the toe, multiple times over.

Thankfully, I was provided a large dose or prednisone at the hospital, which allowed for significant pain reduction within the hour, I was given a script for the rest of the week. I was also given a mild antibiotic (a 1st generation cephalosporin, for those that care meaning that he suspected a gram (+) bug if any at all) in case there was any infective process at work. All I know is that that was a continuous pain, that disallowed me to sleep or think straight for nearly 2 days straight.

As I was preparing to leave and the nurse was chatting with us, she learned that I was a first semester medical student. She said something to the affect that I should've just diagnosed myself. Well, I did, but since I have a few years until I'm writing scripts I figured I should still be seen. Nothing like a Bout of Gout to Sprout Doubt and make one Shout.

Thursday, November 3, 2011

Modern Cave paintings

 Take that, liberal arts.

Thursday, October 27, 2011

Instead of bidding 1 dollar over the previous bid, I might bet 5 dollars over just as a gesture of kindess and empathy.

Today is Thursday, we had an exam on Monday. We have another, bigger exam next Friday, and then the following Monday and Tuesday we have more exams and practicals awaiting us. Thankfully, some of the material presented this week is "reviewish" in that anyone who has had basic microbiology has seen this stuff before. For that matter, anyone who has taken the MCAT (all of us) have seen this stuff before. Unfortunately, there is a lot of bug and drug memorization going on as well -- some of it is familiar, some is not. Many of us (as students have done for thousands of years, I'm sure) tackle the rote memorization of seemingly (at this point, at least) abstract terms by making up sayings, or attaching stories or internal meanings to the words. Tetracylines and Aminoglycosides inhibit the 30S ribosome. I remember this by reciting: I mean, Tetris is for 30 somethings. It works. There are so many of these out there and there are abundant lists to be found on the internet, but sometimes it really is enjoyable to come up with my own relationship with the material we are learning.

On the way to school today, some retired NFL guy was talking about how during the NFL season's bye-week it is important to spend a few days away from the facilities, coaches and fellow players. But he went to great lengths to emphasize that even if a player is physically away from the game, that his mind will never be away, during the season at least. Of course, as most things do these days I couldn't help but relate that to medical school. The week prior to this one we didn't have any classes but I definitely spent most of my time studying. It was our bye-week. I did get to watch the Price is Right, though. Does anyone else think that Drew Carrey is doing a really good job? Don't get me wrong, Bob Barker was great too, but I can't take anything away from Drew's body of work on the Price is Right. He even chuckles when someone places a bid of "420" which I'm not sure Bob ever did, for better or worse I suppose.

Tuesday, October 18, 2011

Fun time is over!

I just posted a blog entry not more than 15 minutes ago. Like I usually do, I don't remember to briefly proofread it until I publish it. So then I go back and read through it. As I was scanning the last entry, I got to thinking that I really need to be documenting what is happening at school more, since I aim to use this blog as something to be able to come back to and see my thought's on things as they are happening. I do think that I've been putting tid-bits in here and there, and I really do enjoy writing down memories of this and that, but I think that I need to add just a little more of the boring, day to day stuff. So, I'm gonna start with that here.

This coming Monday is the Mini-exam for block2, and that is what I'm studying during this fall break. There is also some OMM and doctoring stuff to worry about for the end of the block fiasco. OMM is primarily concerned with Facet Diagnosis, in theory and in practice. In The doctoring lab, we've finally got our equipment and we have continued to learn how to examine each other. We've been learning how to take blood pressure with our Sphygmomanometer and conduct cardiovascular exams. It's all very real and exciting. In Fundamentals we have 6 neoplasia lectures, going all the way from the early physiology of cancer to cancer therapeutics. The pulpit was manned by 3 different lecturer's -- all very knowledgeable instructors. Our neoplasia lab was run by the typical path instructor and of course, our blood histology lab was from our histologist. We also had 5 or 6 clinical immunology lectures, kind of as a follow up to our first full blast of immunology, which was tested on during the previous exam. 

The most difficult part of this exam will be centered on the ability to cold memorize this stuff, as many, many therapeutics are introduced and discussed at length. I'm guessing that there are at least 65 different drugs that I need to know everything about, what they are, where they come from, where and when they work, toxicities and contraindications, etc. There is also plenty of signalling pathways and cascades to know. The nice thing is that so many of the players in these pathways are redundant at this point, which makes for an easier time with dynamic comprehension. Clinical immunology introduces a handful of new drugs, but much of it seems simple relative to the first time we were seeing this material, thankfully. 

My core study routine consists of making note-cards for all the pertinent material. I think there are nearly 500 note-cards, which has proven to be about what each exam needs. While crunching through the PPT I listen to the audio of the lecture, were I often find myself listening to selected parts over and over for clarification. I also have the accompanying text when available. I will be re-reading the selected text as  a whole prior to the exam, because as of now (5 and a half days before the exam) I've only read parts that I needed resolution above and beyond what the PPT's provide. I've already done all of the provided practice questions for the neoplasia lectures and will soon do the questions from the clinical immunology. The nice thing about completing whatever note-cards you may want to have early on in the exam cycle is than you actually have time to use them for what they were created for. It really helps. So, I'll be drilling with those for hours and hours the next few days and then during the weekend I'll go back through and make sure I'm not missing any concepts from the provided objectives. 

And that is what I'm doing this week.

Poop is to life-lesson vehicle as brachial pulse is to ______________?

In the backyard of the house where I grew  up, well -- the split level 2 car garage, (but only ever housed on automobile at a time) single family dwelling where I aged from 3  to around 18 years old my Dad built a 2 story play-house (as we called it) and a sand-box. Perhaps it was not as much 2 stories, but a little fort built with an open roof that had waist high walls all around the perimeter. It backed up to the property line that had a 12 foot tall hedge grown next to over a regular size chain-link fence. The name of the plant, bush or tree -- whatever it was kind of looked like the hedge here, though. They were fun to climb in, definitely. The hedge was nearly as high as the railing on top of the play-house. This meant that behind the play-house was a sheltered kind of a cool hiding, cave like place.

When I was in kindergarten I went to a elementary school, which is now a Montessori school and every time I drive by, the building and campus seem to get nicer and nicer. Granted, I only drive by once a year or these days, so maybe I just forget that they painted this or that. It was within the last couple of years that I actually stopped and got out of the car and went to the playground. In Portland, many playgrounds have this large structure that has no walls, only a high, usually slanted roof -- this is so the kids can still go out at recess even when it rains. We had many "Undercover-only recesses." Underneath were basketball courts and the like. When I was in either the 2nd grade or 3 grade, or, for that matter, 1st grade or kindergarten I remember we painted a huge map of the United States on the asphalt under neath the Under-Cover. It was still there, 25 years or so later. At some point in my elementary school career the empty lot that was across from the school grew a Fred Meyer, which is a one-stop-shopping-center. When in the Pacific Northwest, feel free to cal it Freddys. What was cool was that there was, at least at some time a crashed airplane that was hauled there after it crashed on 158th and Burnside in 1978. In fact, I really don't recall if I actually saw the fuselage and such there on the empty lot (pre-Freddys) on 148th and Division or if I just knew that at one time, there had been a crashed airplane on the lot. Didn't matter though, I will always remember that lot in what now is not such a nice part of town as the crashed airplane lot. Here is the information about that crash, that occured 75 days after I was born.

We lived quite close to the school, so much that I remember walking to school. I'm sure the first year or so It was with Mom. Eventually I would just meet up with other kids in the neighborhood and walk with them, and then walk home after school by ourselves as well. I remember one day better than the others -- the day that I pooped outside between the play-house's backside and in the thick, lush hedge. I think I was there with a friend, and we were waiting for my Mom to get home, but, I really, really had to go. So I went. And that was that. I have a vague feeling that I may have feared getting in trouble, but was really excited having poop in the hiding spot and maybe I could get a friend to step in my poop or something. In fact, I'm not really sure why or even if I was really excited about dropping a deuce in the backyard. What I do remember is going back the next day, and the next and the next trying to find the steaming pile. In my mind, it was going to stay as I had left it. Most likely it just rained all day and night, like it does in Portland and it just kind of moved along, washed away like every other turd in the history of mankind. Another good question is why I was so disappointed that it was now gone, just a short day later. I'd like to believe that it was some sort of deep truth learned about the constancy of change that we live with. And, I'm sticking with that. So, maybe I did grow up just a little bit at that house.

You cannot see the sandbox on what was (is?) the southern hall of the play-house. And, yes, there is the hedge as well.

The recall of this experience was catalyzed by an effort to recall my earliest memory. This was not the earliest, as I was at least in kindergarten (but probably a year or so older than that) and I, for sure have a memory of a spring-time day that occurred in year three, meaning that I was around 3 and a half years old. I remember walking out the side-door of the church that I grew up in, I was by myself and when I walked out it was a bright, blue shining day (these are memorable in Portland, no matter what the age) and then looking at the big, mature Oak tree (actually, thinking back I'm not sure if it was an Oak tree. If anyone knows what that tree is I'd like to know. I can picture the little helicopter thinks that would come off of it). Anyway, I looked at the tree and I though to myself, 'I am three.' Ever since that day I've always held on to that day. Sometimes I don't think about it for a few months at a time, but then something will just trigger that memory and then I'll pause and think about the day that I knew I was three. This may not be my earliest memory either, as I can remember living at the house that my parents had before the one with the play-house. It is very foggy though.

This is amazing to me -- the brain and it's ability to take in and store information. There will never be at time, barring some neurological injury or dementia, that I won't remember the day I knew I was three. It probably will be something that I would be able to recall even if I did have, God forbid, something happen. It may even be there after going through medical school, which is arguably more of a feat. Insert here: brief, obvious but poignant comment about the constant information diet med school students the nation over have been binging and purging.

Sunday, October 16, 2011

A new meaning of the word "eighth" for me.

Last night I was at a comedy club in San Francisco with some friends and my wife (not that she isn't also my friend) and, lo and behold, actually laughed. We saw Steve Byrne and an opening act, and even though I wouldn't call it the best show I've ever seen, we were laughing pretty much the entire time. Going to the club was a belated birthday present, especially picked out because my wife said I haven't been laughing enough lately. Well, that is probably true. Endless memorization of signalling cascades can do that. It was definitely nice to get out, especially since this upcoming week is our fall break. It will be void of lectures and labs, but there is more than enough to keep me busy, especially since next Monday morning opens with an exam -- what a nice way way to welcome us back.

As many of you know, medical school in the US is comprised of a total of four years, with the first two being (almost) exclusively classroom/lecture instruction, and the last two being all clinical rotations, where students spend six to eight weeks being involved in a specific specialty (surgical, internal medicine, OBGYN, etc). So, having the first two years so divorced from the experience of not only the second two years, but the real world experience of practicing medicine, I and many of my fellow students are focused on just getting through this first phase with the best grades possible and a good board score. We are just over the half-way point of the first semester, of the first year. This means I am 1/8th of the way through what many people have identified as the most difficult phase of medical school. It kind of feels like I just started, which makes sense, as it hasn't yet been three full months of school. On the other hand, life as it was prior to school seems like a distant, foggy memory. I still wouldn't trade this away though.

Thursday, October 6, 2011

So me and this Alkylating agent walk into a bar . . .

As this week's classes draw to an end (thankfully, we get a long weekend) and we finish our first foray into the science of cancer, I can't help but take a step back and contemplate the larger life lessons that cancer can teach us. Nearly two years ago I penned a short story which is still my favorite piece of writing that I've ever produced, even compared to this blog, unbelievable -- I know! It basically follows a world renowned cancer researcher  and his wife, who is dying of cancer. The researcher's lab wins the grant which allows him to get a new (fictitious) neutrino microscope which enables him to obtain resolutions much higher than an electron microscope. Of course, he peeks into the cancerous cells of his wife, only to find much more than he bargained for. (After finishing writing this post, I thought that it might be nice to include a link to the story. I copied the shortest, polished version (the published version) to a google document, so here is the link: Apoptotic Adventures While Whale Watching.) I hadn't read this story for quite some time. The last time was way before I made it into med school, and after revisiting it I'm glad that the science isn't completely incorrect -- with that being said, I'd change a couple of things if I were to get serious about it again.

This post isn't about a story I wrote, but rather, one of the issues I tried to touch (mostly unsuccessfully, but with short stories you really have to pick your poison) upon in the story. That is, the nature of cancer. Here is the thing, the more we learn and understand, the longer the list is for carcinogenic things. Chemicals, of course, but also bacterial and viral infections can cause cancer. Spontaneous genetic mutations or lack of exercise can all spur cancer's come-on. However, one thing all cancer in all parts of the body has in common is the refusal of at least one cell to die. And then, this cell recruits more cells in it's cause of selfish survival. In our bodies, at all times, cells are dying because that is the way things are supposed to go. Whether it be from old age, improper formation or some kind of injurious agent, the cell knows when it's time to go. A cell with cancer says "no way, I'm not sacrificing my life for the good of the organism" even though without the parent organism, the cell would've not existed and because of the refusal an immature death may befall the rest of the cells that comprise the whole organism. Does this attitude sound familiar to you?

Even though I am going to die, one way or another, I am willing to sink the whole ship in order to prolong my own life for a brief moment. This is despite the fact that the ship is a sound vessel and undoubtedly has many decades left of service. This is the attitude that the cancer cell has.

I'm sure you've been in a construction zone where one of the lanes merges with the other one. This is not a case of a last minute merge, we're talking about signs for at least a mile prior to the merge. Everyone who is driving knows there is a merge coming up. Most people take the first opportunity to get over into the lane that continues. However, we can all remember (I'm sure it has never been any of you!) the people who speed to the point of the merge and honk and force their way in, despite those who have been driving in a manner which benefits all those around them. These jerks are the cancer cells. I can remember a few times in these situations, where the backup was just horrible and a driver of a larger truck, who had been waiting in the through lane moved over so that the cancer cells couldn't speed to the front of the line anymore. I consider these large trucks to be the equivalent of anti-cancer drugs. Probably resembling the alkylating agents, as they don't destroy the car (cell) but just disable it from speeding to the front (metastasizing or invading surrounding tissue). I wish I could buy those alkylating agents a beer. I have a feeling I'll think of a better analogy when I'm trying to go to sleep tonight, but this is one I've actually had in mind for a long time, believe it or not.

There is no doubt that the signalling pathways, molecules and cancer drugs play a huge part in my education and I'll strive to know everything that I can about them. There are times, however, during my moments of introspection (which are of lesser quantity these days, but I think the quality has suffered less than I feared) that I have to wonder whether or not the cancerous cell is just mimicking the actions of the whole organism. Perhaps a question better left to the philosophers of our day, not the physicians. However, I've always hated the idea of being a one-trick pony.

Monday, October 3, 2011

When I was 22 years old, I was a contractor who, for the most part worked as a subcontractor for a couple of warehoused who contracted with different property management groups and small apartment buildings for floor covering replacement. It was lucrative work with minimal headaches, as most jobs could be completed with in the span of a day (granted, sometimes the days were excruciatingly long) and there was no sales or bidding of jobs -- which is really a headache. Work was often cyclic with the summers being the busiest times.

I remember the summer when I was 22 quite well. It was the summer that I eventually made the decision to get out of the construction business and move to Colorado. But that is a different story (kind of) and several months before I had the inkling that I would be moving out of Oregon (born and raised in the eastern edge of felony flats of Portland) I found myself trying to manage the flow of work, which was good. Between myself and my crew (a couple of friends who had as much experience as I did in the business, making the "boss" a title in name only) we sometimes came across apartments that needed carpet and pad replacement that still had quite decent padding. Perhaps the tenants made quick work of the carpet, staining it with various fluids (that I won't go into) and who knows what, but the carpet wasn't actually that old. These cases were candidates for leaving the existing padding, and just installing new carpet over the top. After all, who would know? This was especially tempting on concrete subfloors, as it means the pad was glued down and was really a pain in the rear end. Really, except for the fact that the property owners were paying for product they weren't actually getting it was a high reward, low risk type of risk.

One afternoon, somewhere in the west hills of Portland, I got a call from the warehouse manager who called to inquire about a unit that my crew had done a few days prior. It was a unit in the same complex that I was working at when I got the call -- we had actually been there working all week. The manager asked me if we had replaced the padding in the other unit. I could tell she wasn't happy. After a big breath and a big cringe, I decided to 'fess up. I also told her about another unit that we did in the complex without replacing the carpet padding. 

This is not one of those stories where I do the right thing, never to make another mistake again. This was just one in a long line of lessons learned. I really have no idea if that warehouse manager even remembers me, or that incident, but I sure do.

I was thinking about this today when I had the radio on coming home from school and the radio guy was talking about the 49ers win over the Eagles yesterday and how he thought that just the fact that they were able to pull off the comeback would yield one or two more victories this season. He wasn't saying that the abilities that got them the win yesterday would pay off, but that the momentum and the confidence that arose from the specific parameters of the victory was valuable in and of itself. I can't completely disagree. It got me to thinking about how I've heard others say (and have been known to say myself) that 'you just have to fake it until you make it.' Well, I would argue that faking it only goes so far, unless you do, indeed 'make it' at some point. I'm sure we can all envision that character who has shown so much confidence but failed to produce anything of value. That person sure was faking it, but just never made it.

That one incident, in what at times feels as if it were from another life, kind of allowed me to remind myself that I could indeed stand up and do the right thing. By no means have I always done the right thing in every situation since then, but I do think that it may have gotten me out from under the temptation to do the wrong thing, at least once or twice since then.

In medical school, we are taught to introduce ourselves as "student-doctor Smith" while in our doctoring labs, and I'm fairly sure that is how we'll be instructed to do it once in the clinical setting, you know, like, for reals. Perhaps I should amend that 'fake it 'til you make it' to a more situation appropriate 'forsake it 'til you make it' as far as thinking of myself as a doctor. Obvious, but sometimes I can get ahead of myself, no doubt. Especially after killing the test this morning -- finally, a performance I can be proud of. Granted, we haven't gotten the results back, but I already know that my amended studying techniques have payed off. Thank God . . .

Wednesday, September 28, 2011

Guess Mess

The principle that has medicine as an art, in my mind, is what marries the science with the guessing. There have been numerous times in the past few months where we've been told that practicing medicine is really just an investigation that one needs to proceed with to try and arrive at the junction of making a diagnosis with the most information possible. What seems strange to me (or perhaps, felt strange to me) is putting this in the terms of diagnosis being nothing more than a "best guess." Maybe it is the terminology. As I learned the hard way yesterday with a quiz I mis-studied for, the language of medicine is often just renaming principles and structures we already are familiar with, with terms that are often (literally) Greek to me.

Had I tried to articulate this idea prior to entering medical school, I could've probably come up with this, but as I've learned over and over, for me, ideas often take awhile to manifest in realization and/or action. I think there was, and may still be, a part of me that holds the idea of being a doctor on a plain that allows for instant knowledge retrieval from an infinite reservoir. While this is clearly ridiculous, there is something to be said for having the largest possible knowledge accumulation possible, as being able to come up with the initial differential in one's mind is quite an advantage. This of course, is scope of practice dependent and complicated internal medicine cases and the like should always be cross-referenced via resources, including texts but also other physicians.

Here is to being the best guesser I can be.

Sometimes all I can think of when "guessing" is discussed in a lecture is the movie "The Jerk" with Steve Martin which has him working as a "weight guesser" during his time with the Carnival. And that's the only thing I need -- is this book. I don't need this or this. Just this laptop... And this note-card. - The laptop and the book and that's all I need... And this stethoscope. - The book, the laptop, and the stethoscope, and that's all I need... And these scrubs. - The book, and these scrubs, and the stethoscope, and the laptop... And this highlighter. - The book, this stethoscope, and the laptop, and the highlighter, and that's all I need. And that's all I need too. I don't need one other thing, not one... I need this. - The laptop and the book, and the highlighter, and the scrubs for sure. Well what are you looking at? What do you think I'm some kind of a jerk or something! - And this. That's all I need.

Monday, September 26, 2011

I am now at the point where the reality of what others have testified of, in terms of living a life where almost nothing can occur outside of medicine, is my reality. I'm struggling to fit in sleep, much less running and time with my wife.

We have a shortened week at school due to the upcoming Jewish holiday, so I'll be able to catch up on a few things, the least being this blog.

Sunday, September 18, 2011

I've got friends in crawl spaces, with their heads in jars and their arms in vases. And the thunder rolls, and lightning strikes.

I think the main reason that so many people, especially interacting strangers, end up conversing about the weather is that it is one of the few things that everyone has in common. I don't think that it is a stretch to say that at Kaladi Bros Coffee, every day that I worked had to involved at least a passing comment about the weather -- granted, Denver has some incredible weather and it is one of the things I will miss about the Front Range. The house that my wife and I have in Denver and in which we spent nearly the last four years sat on a hill overlooking Central Denver (we could see the Auroria Campus and the Pepsi Center from the front of the house) and massive storm heads building to the East of town were a sight to behold, for sure. The thing is, the way the house was situated inside, there was really no vantage point for sitting and staring out the window. The room in which the office was set up had a nice view across the Platte River Valley (officially, it is called a river, but I think of it as a creek -- at best a stream) into the Downtown area and I spent way too much time staring out the window -- but then again, would I be studying medicine at Harvard had I kept the blinds closed more? Whatever. 

The summer view, from the computer chair in the office of the Denver House.

Today, as I spend a couple of hours relaxing, as there is no material from school that I am immediately responsible for, I stare out the front window from our living room at a view that quite honestly, is amazing. The window in the office at the new house is twice as big, but stares across a walkway directly at a blue wall, which is the other, smaller house that sits on the same property as our home. This home was actually just rented a few days ago, and the new tenants will not take residence for another month. It has been nice to have the property all to ourselves since July, but I recognize the need to rent it out -- especially since we are landlords ourselves. Sometimes I have to escape the office, which is necessary no matter where one studies.

View from our living room couch, looking out over the C&H Sugar Factory (which never returned my skeleton that was erroneously dropped off there) towards the Glen Cover area outside of Vallejo. 

Before I moved to Tampa, Florida a little over ten years ago I really had very little exposure to powerful thunderstorms. In Portland, Oregon, electrical storms, or even powerful storms are relatively rare. This may sound counter-intuitive but it just calmly sprinkles for the majority of periods of precipitation. Days like these in Denver are nearly unheard of, and those that we received were holiday-like for me. Perhaps the first time I really was struck by the intensity of a thunderstorm was in Edmonton, Alberta. I spent a summer there as a young teenager, and among many memorable nights I remember one where it was dark outside, meaning that it was quite a-ways into the night since the sun sets so late in the summertime due to their extreme latitude. I remember it being 15 or so of us, a sitution where everyone except me took it for granted that when the downpour began, we were to head out to the large trampoline in the back yard and get crazy on it -- while pouring liquid laundry detergent all over the nylon surface of the trampoline. In the pouring rain, watching the frequent flashes in the wall of clouds engulfing us, they then turned to identifiable lightning bolts which seemed to feed the fervor of the crazed kids on the trampoline. Someone got drop-kicked right off the trampoline into the fir trees. People landing on other people, others unable to get up from the trampling of the trampoline jumpers. It was awesome.

The next electrical storm that really got my attention occurred in a subdivision in New Tampa (which is a horribly named subdivision north of Temple Terrace, or something like that) on duty for one of the worse jobs that I've ever had -- granted, it didn't have to be as bad as I made it, but let's just say I learned a-lot from my time at the Store of Floors which sits not far from Raymond James stadium, where the Buccaneers play. Not only did I learn the craft of high-end floor installation, but I learned how much of a role I play in my very own well-being - truly a concept for the ages. The couple that owned the business only employed one other person, a long time, disgruntled man who was a Vietnam Veteran from Buffalo, New York. For the most part he treated me well, interspersed with some scathing episodes of verbal abuse.

One afternoon, in a section of subdivision new construction where the section of houses that we were installing floors in did not have power to the individual homes, but instead there was one pole every 2 or 3 lots, and the contractors would have to run heavy-gauge extension cords to run any necessary equipment. I'm sure it had been storming for days, a monsoon end to the summer in the other "Bay Area" I've lived in. It had rained enough to form a solid lake, with the pole that had the electrical drop smack in the middle of. I was told to take the extension cords and get us power -- great. I slodged through 20 meters or so to get to the middle of the small lake, which had me in mid-calf deep muddy water with rain pouring down all around me. I remember thinking that this was not how I wanted to die. I slammed the extension cord into the bank of outlets anyway and ran for it. Obviously, I was not electrocuted, that I remember -- granted I was probably faster ten years ago, but I probably would have a hard time outrunning the electricity even then.

Colorado, no doubt holds many memorable storms for me. One in particular for not the sheer size of it alone, but because I remember it happening on a afternoon spent playing in the creek in the foothills town of Lyons with some friends where I think I may have, for the first time felt at home in Colorado. I think prior to that afternoon, which occurred at least a year in to my 8 years Colorado stint, I imagined myself moving on, and sooner than later. I'll always look back with great fondness for those days.

A lake outside of Leadville, CO in the shadow of Mt. Elbert (14,433').

Even though many, "how's the weather" conversations may seem superfluous and at times, downright unnecessary, I think we as (especially here in America, where stark, unwavering media-driven opinions are the norm from so many people no matter the ideology) need to at least communicate with those around us, even if it seems insincere. I would argue, just reaching out and addressing a stranger, even if it is just to comment on the weather, is definitely is a positive thing.

Tomorrow, when I spend another 8 hours in a darkened lecture hall, I'll be sure to appreciate the requisite sunshine of the late afternoon here in Northern California as I drive home to implement my new and improved study strategies. I've been mulling over the idea that perhaps I would feel like this after every block exam for the next two years, but then again, the first time must provide the overwhelming number of lessons, which makes sense. We don't have our grades for most of the exams from last week, but I do know that in the 2 or so weeks between the first mid-block exam and the full block exam I implemented a few changes that were beneficial, which I am thinking translated to better scores. The last we took last week was an anatomy practical. I think there were 124 items we needed to identify and I was dreading this immensely. Now, remember that we don't have our scores back yet, but I actually feel as if I performed better than I feared I would. Things like that are immensely encouraging. It definitely helps me remember that I can do this, and that now that I feel like I have a sense of the work load and what exactly it'll take to perform well in medical school, I will. It makes pouring over the residency programs enjoyable versus terrifying. So, with blatant disregard for horrible cliche-like engagements, here is my admonition to everyone so that they would stop and reflect and if possible, enjoy the small, little moments in life.

Friday, September 16, 2011

I haven't been to Warm Beach Camp since they eliminated the sulfur tainted water. I'd miss the boilded egg smelling Kool-Aid.

When I was younger, I had two favorite days of the  year, one was Christmas morning, and the other was the first day of Warm Beach Camp. I guess I really don't know young I was. I at least had a firm grasp on how the calendar year works, because, you see I thought it appropriate that since camp usually started the second week or so of July that it provided a nice, balanced bi-annual day of anticipation. Warm Beach Camp is located one of the inner fingers of the Puget Sound, north of Seattle and was a major highlight of the summer.

I've been thinking of a time when I went on a horse-back trail ride. I had wanted to go on one for a number of years, only because I had images of full gallops along the water, urging the stallion ever faster. What it ended up being is a long line of horses, 20 or 30 us, with guides interspersed between 3 or 4 of us. The camp itself, sits on a bluff that ends in an abrupt drop of a few hundred feet down to the water of the Sound. The cliff was not so steep that trees couldn't grow, but if it was much steeper it would have been a sheer granite faced cliff. Criss-crossed through the woods were many trails, and it was one of of these, running along the hillside where our group found itself, plodding away CLOP ---------- CLOP --------- CLOP. Very slowly.

What happened next I remember as if it happened to the horse and rider directly in front of me. The image that is burned into my memory is of the young woman who was a guide in front of me along with her horse falling sideways into the brush and giant David Douglas Fir Trees filled drop off below our trail. If I'm remembering this the right way, the horse fainted (equine syncopy induced trauma is heavily tested on the boards, or so I've heard) or died, basically falling to it's right side and just free-fell. Of course the rider didn't expect this, and I can, even now, visualize them landing, in the same form as they had started, with the rider straddling the horse, and coming to rest a good 20 or so feet down the hill. I think they just landed and stayed put, with no traumatizing tumbling or smashing into timber. And they just laid there. After some of the guides scaled the drop to help her out, some of the other guides got the "civilians" out of there, many of us were crying. I may have been, but I kind of don't think so, I've never really reacted to events like that with crying -- not to say that I didn't cry. I'm sure a couple of them either radioed or engaged in a full gallop by the water to get back to the stables and help. I'm also sure of another thing, I remember being told that the girl only suffered a broken leg, but that the horse didn't make it. I wonder if that's all that really did happen to her? If so, I'm most likely "over-remembering" but, nevertheless, it was the talk of the camp for the rest of the week and I remember being so pleased that I was the one who everyone wanted to hear the story from. How sick is that? But, when the older kids and the cute girls are giving you positive attention, well, let's just say I wasn't one to let that opportunity pass.

Another story youth camp trauma happened when I was older and I'm sure I remember it with much more clarity. This time, I was at a camp near Sun Valley, Idaho that occurred over Labor Day weekend, and while this annual gathering wasn't as long lived as Warm Beach Camp (which still goes on year after year, which is impressive, good job to everyone involved) but was a three day action packed less supervised (which didn't necessarily mean we were up to no good, but provided a good atmosphere for good (and, yes, of course bad too) free wheeling fun). Yes, that was just a parenthetical inside a parenthetical (I've realized over the years that parenthetical mechanisms are a major component in my communication (and my inner dialog), for instance, when I'm conversing with someone, I'll often cite a fact, or occurrence of some kind that is pertinent, and attached to it is a beneficial element that lies in an immediate expression of the fact or incidence as it enhances either the effectiveness or quality of the initial thrust of interest) and I try to limit their occurrence, but I'm in a good mood today, so I yielded to the temptation.

The camp here was much more isolated and in one of the most beautiful places I've ever been. The camp was on the shore of a small lake, perhaps a mile, at most across. However, it was fed by a creek that was at the terminal end of a much, much bigger lake at the foot of a stunning peak in the Grant Teton range. The small lake was so clear at points that one could easily see 30 or 40 feet down, through the water. Large schools of fish were abundant and boulders and logs on the  bottom were easily identifiable when in a canoe on a sunny day. The camp had two docks for our use, on was in a swimming area and the other is where the canoes were kept. People were not supposed to swim here, but it was much better for it, as it was much deeper and the swimming dock sat over hip deep water. Also, imagine 2 floating docks, about 15 feet away from each other as they extend into the water, this is how the boat dock was situated. However, they are connected by a bunch of 2X4's at the terminal end, providing stability. It also provided a place for gladiator like contests with two people duking it out with life-jackets fights (like a pillow fight), or perhaps oars, trying to knock the other into the water. This happened all the time and there was never really an issue -- maybe, once in awhile someone would say something about not swimming there, if they did it was halfheartedly and non-commital.

A very popular thing to do when I was growing up involved the dire need a young boy feels when near a body of water. The unexpected push-in of a friend or a cute girl was so irresistible that I can't help wondering what happens now, in the world of constantly carried cell-phones and personal electronic devices. Do kids still do the push-in, in the same manner that we did? If my child had a few hundred dollars worth of electronics ruined due to the push-in, I think I'd split my frustration not only at the fact someone pushed him or her in, but also that this is the state that we live in now, constantly armed with electromagnetic devices. Secondarily, I'd be concerned that I didn't teach my child well enough so that they'd anticipate the push-in  and shed the devices in preparation for the push-in. Anyway, I guess this is a good time to apologize to anyone who received the push-in from me, I'm sure I'm guilty of more than a few unrepented wettings. So, if you ever see me again and you're worried that I haven't outgrown the push-in, rest easy my old friend, I've moved on. Now I'll just want to palpate your ischial tubercles and try and diagnose your latest and grossest. An improvement? Who's to say?

This push-in from my past, I'm glad to say was not one that I am guilty of, thank goodness. A foursome, two girls and two boys are on the dock, hanging out, two of them are my cousins. I don't believe we were planning on a canoe trip, but only just hanging around. Of course, my compadre, a good lifelong friend of mine initiates the push-in. I remember it like this. My friend pushed the first girl in with the surprise push in the back, and while trying to get the second young lady in (me thinks she doth protested much) she managed to drag him in with her. Tumbling into the water together, they untangled beneath the surface leaving both of them disoriented. They both got their bearings and swam for the surface, the girl, seeing she was under the dock, engaged in evasive maneuvers, and in doing so kicked powerfully to get her to the surface. As she was nearing the surface she was oriented so that she was face-up, in that that when she kicked, the dorsal area of her foot faced the surface. Or, in this case, it slammed into the underside of the edge of the dock. Right where there happened to be a huge, rusty, algae covered nail. Actually, "spike" provides a better image, as it was several times larger than a 16-penny nail. This pierced her foot, from the top and then exited her foot on the inferior side. She was pinned there, forced to tread water, on her back, with one of her feet secured to the underside of the dock, which, of course was near the surface. It all made for a very uncomfortable place to have to stay afloat. I remember her saying during this that her foot was caught, that is, she thought that it was just lodged between some boards or something and that she tried mightily to pull it out. Can you imagine what this might do to the site of injury? Thankfully, the water was not far away from its origin, which was either the snow pack or the glaciers that lived high on the mountains surrounding us -- it was cold. Eventually, some of the adults were brought down to help and I remember a man (again, I vividly remember who did this and looking back it was one of the many things that have spurred my desire to work in emergency medicine -- to be capable in these kind of situations is something I find intriguing and desirable) who spent a good amount of time getting her foot off the spike. The water was so cold she wasn't losing copious amounts of blood. Other people took turns helping the spike-stuck-girl stay above water with the aid of a few life-jackets. They got her out of the water and drove her into Sun-Valley, which must have been nearly an hour away. She was fine, and was back later that evening.

I'm not sure, but I think that might have been the end of my push-in tendencies. If they weren't, they should have been. I guess I have taken lessons from others' experiences -- Who would of thought?

Since I've rambled on this long already, I want to expand on my thoughts about the parenthetical manner of thought that I find myself constantly in. I think that it has been, and will continue to be valuable while in school. Learning about the human body in the context of medicine really is like one big parenthetical. Every thing that I learn about, is connected to another thing, and so on in perpetuity. This is obvious, but I had just not put into the context  of my previous existing self parenthetical theory until now. Lectures given have parentheticals that are concerned about the pathology of a certain function, which leads to another that speaks to the appropriate and inappropriate treatments and so on. Looks like I chose the right field.

Thursday, September 15, 2011

Uhh, Hmmm. What? Okay. Wait a minute, what?

"Of course it happened to me, because that's just how things go." Do you ever find yourself saying that to yourself whenever something unfortunate happens? I found myself, this afternoon thinking that exact thing, as if my life had been one long string of unfortunate incidents, as if there were a grand scheme to screw everything up for me. This is a dangerous trap; one that is easy to fall into but getting out of posthaste is imperative.

So, the last day of block exams we had to deal with three separate exams. The middle one was a doctoring practical that basically was identifying surface anatomy landmarks and palpitation. You know, find the thyroid cartilage, identify the left middle lung (okay, trick question, you got me, there is no left middle lung!) and the auscultation points of the four heart valves, and much more. In fact, we (the students) were provided a page of landmarks that constituted a predetermined set of things we were supposed to know going into the exam. Great, sounds good.

The exam starts with having me find 4 different pulses. Excellent. Then I am asked to identify the lobes of the anterior upper lungs -- again, no problem. To finish off the exam, I am asked to identify the exact auscultation points for the upper posterior lungs. Oooooookay. From simple deduction, I can figure out (on the fly, no less) that it is not a good idea to listen to the lungs through the scapula. So, I try and pass it off by saying that just medial to the scapula, superior to T3 but inferior to T1, in hopes that's good enough. You see, this wasn't on the rubric provided to the students. If it was, I would've known to point out rib 4 was what the proctor was looking for. I didn't, because I didn't know it was going to be asked.

Of course, this was the moment I began to think that of course, this happened to me, because that is just precisely what happens to me. In the grand scheme of things, this isn't a big deal, and even during the exam I knew this and I was never in danger of losing perspective. In these doctoring exams they partner you with another student. In this instance, I was the student who was the "doctor" first. When my fellow student had her turn, she was asked to provide landmarks and palpitations that were listed on the rubric. She did just fine, but as the afternoon progressed, I couldn't help think (and in the process, get caught up in the trap) that these things are just the type of things that happen to me.

Like I said before, these things are amplified in our minds, especially when we're so focused on these exams, determined to not sacrifice any points to lack of preparation. And, now that the week of exams if over, and I had some nice Indian food with the wife and now am watching a movie on the couch (Cedar Rapids, if anyone is curious, which is the kind of movie I like, especially with Dr. Steve Brule in it -- for your health! Maybe the happy ending is a little too much) with the same wife, and life is good.

For someone in my position, who admittedly, has gotten away with more than I deserve, it is important to remember that the world isn't conspiring to foil my plans. After all, my car did start this morning.

I'm sorry for the lack of entertainment value in this post. I'll have some good stuff this weekend after a good night's sleep. Hang tight.

Wednesday, September 14, 2011

1st Block Exam week.

This is what this week has felt like. Three more tests tomorrow. Unfortunately one of them is the anatomy practical, for which I am not prepared as I should be. One way or another tomorrow night will get here though.

Wednesday, September 7, 2011

If Sabonis had come to the Blazers when he was drafted, many more people would consider Kobe to be a better player than MJ. A strange dichotomy for Blazer fans.

The following excerpt is not only from the book mentioned, but directly from TrueHoop which is a long standing favorite blog of mine, not only because Henry Abbot is a Portland native but because in my opinion, intelligent discussion involving the NBA is severely lacking (why this is is up for debate, but the vacuum seems to extend from the playgrounds to the mass media) and TrueHoop brings the best commentary together in one place. Anyway, this idea espoused by Michael Jordan is one I've heard before, but recently I've been thinking about the principles in a different manner. Discussion will follow the excerpt.

In the book "Driven from Within," Michael Jordan talks about his crunch time mentality:
If I miss a shot, so what? Maybe even a shot that could have won a game. I can deal with that. If I don't miss the shot, then I don't miss it -- we win. I can rationalize the fact that there are only two outcomes: You either make it, or you miss it. I could think that way because I knew I had earned the opportunity to take that shot.

I had put in all the work, not only in that particular game, but in practice every day. If I missed then it wasn't meant to be. That simple. It wasn't because the effort wasn't there. It wasn't because I couldn't make the shot, because I had taken the same shot many times in every situation. As soon as the ball went up, there weren't any nerves because I had trained myself for that situation.

I was as prepared as I could possibly be for that moment. I couldn't go back and practice a little harder. I knew I had done the right things to prepare myself for that situation. One way or another, I knew I was prepared to be successful. Now, if you know you haven't prepared correctly, or you know you haven't worked hard enough, that's when other thoughts and emotions creep into your mind. That's stress. That's fear.

It's the same process for doing anything, anywhere in life no matter how big or small the stage. ... If you are confident you have done everything possible to prepare yourself, then there is nothing to fear.
 On the Truehoop blog, there are some good points as to why not every player in the NBA (if any, really) should think this way. Basically, the idea is that basketball is a team sport and going into an end-of-game scenario, the person who takes the last shot shouldn't necessarily be predetermined, and that the unfolding play should dictate who takes the winning shot. I couldn't agree more.

I hope to follow a path into emergency medicine (I think) and compared to many other areas of medicine, decisions need to be made quickly and often, without adequate information. This means, at times, life saving and ending decisions are made by making the best guess. In order to make the best guess, the most complete scenario needs to be compiled, which means that more preparation can lead to better outcomes. Nailing that jumper over Byron Russel (yes, I do think he pushed off -- would you have made that call as a ref?) is impressive. MJ's preparation undoubtedly led him to that point. I hope my preparation will lead me to a point where lives are saved, that might not otherwise be.

As is evident by this blog, I've been relating many things back to medical school in my life. Hopefully readers of this blog will understand this, as this is an outlet specifically for just that: thoughts on med school. I don't care how many Team Based Learning exercises the school wants to put us through, I don't think they will ever allow Team Based Exams, and that really is the crux of it, isn't it? Just as life is, so is this whole process, we are born and die by ourselves (I would argue that even twins experience the birthing process in a solitary manner) and we take exams by ourselves. In medical practice, there is a move towards team based care, which I am not disparaging here, as the goal is to provide better care for the patient. However, the buck stops with the physician, who is, after all, the lawful leader of the team. The EMT won't be named in the mal-practice lawsuit (even if there was wrongdoing on their part, depending on the setting of the care, there is much less money to be had for going after the EMT). When it comes time to prove my skills and capability, whether it be an exam or a clinical situation, I really do want to know that I did all that I could to prepare. Striking the balance between having a semblance of a life and continuously studying is important. There will always be another concept that I don't fully understand -- just like there were more windsprints and freethrows for Michael Jordan to do. However, I think the body when it's physically exercising provides better feedback as to when it needs a rest compared to the mind/brain, which can talk itself into a downward spiral of no rest and only studying. I'm trying to strike that balance, writing this is part of that. I was becoming frustrated trying to calculate membrane potentials and after a period of mounting anguish, I decided to take a break.

Okay, break over. Let's see here, the Nernst value for sodium is +67  . . .

Saturday, September 3, 2011

Skate or Die, Dude.

I've been thinking for awhile that I really wish I could look inside my body. I not talking about any scope or imaging technique, I'm thinking about actually peeling back the layers and looking at stuff. I look back through my life and for the most part, I've been engaged with some sort of damage inducing activity -- that is, more than just the everyday life toll. When I was a wee lad, I really loved playing soccer and I played on a team for a number of years (4, maybe 6 or 7 years perhaps) and I can remember a few booboos incurred during those Sunday afternoon games. Then I started to fall in love with basketball and I played that all the time. I remember being on a middle school team that took a trip down to Coos Bay, which is on the southern Oregon Coast. In one of the first games I crumpled to the ground after a large pop from what most likely was a dislocation of my patella tendon. Ouch. But up until then, my exploits were nothing more than the expected bumps and bruises that are to be expected. Then, I found skateboarding, which was an all consuming passion for the next 10 years or so. In fact, even now I'll still think about things in terms of being a skateboarder. I notice the quality of concrete and asphalt wherever I go, I look at stairs, rails, ledges and embankments as if I still had a skateboard in my trunk, ready to go. I even dream about skateboarding, albeit much less than I used to. To be clear, especially these days, with so many people pushing around on those long-boards, I would have never been caught dead on one of those, and still won't If I can't ollie up a curb or kickflip on it, I don't want to be on it. Whatever though, I begrudge them less than I do rollerbladers, but all of this is tangential to my point. As soon as I started riding a skateboard, I began to destroy parts of my body. Even to this day, my wrists, ankles, palms of my hands, left hip and elbows are weakened and noticeably hampered either by asymptomatic scar tissue or hindered range of motion. I can remember joking in my teenage years, saying that I will "regret this stuff when I get old." Due to the loss of range of motion and specific angles of strength, I'm convinced that I am not able to spin 360 kickflips (regular stance, not that I ever had them down switchstance, but at least I could spin the board . . .) because of damage to my right ankle. Oh well.

Of course, snowboarding took it's toll on my body as well. Off the top of my head, I can think of 5 left shoulder dislocations and one right shoulder separation. I can think of 3 other left shoulder dislocations off the slopes before I finally had stabilization surgery. After the procedure, I remember being chastised by the nurse during a followup visit because I wasn't keeping my arm in a sling. I told her that it really wasn't hurting any more and that the sling seemed unnecessary. She then printed out the surgeon's notes and had me read them. She pointed to a section where the doctor made notes about massive damage not seen on the X-ray (they didn't have any soft tissue imaging done prior to the surgery) and that he was now concerned that the level of trauma and deterioration to my shoulder may cause massive complications down the road. This was in the actual surgical documentation.  Hmm. She then reminded me that all trauma I had incurred over the years had probably severed some nerves, lessening the pain, which was good in a way but obviously very dangerous. So I continued to read how the surgeon had to anchor some muscles in atypical areas and was basically hoping for the best.Thankfully, my left shoulder is in remarkably good shape. Thanks, doc.

I would really like to be able to peel off the layers of muscle and see exactly where he put stuff and then analyze the placements to see how the changed angles affects my range of motion. I'd also like to see my left Greater Trochanter and relive all the times I smashed into the ground off of my skateboard, sometimes from frightening heights. While I'm at it, I'd like to pull apart my knee and look at all the little floating pieces of torn cartilage and the degeneration of the meniscus, reflecting back on all those times I played pickup basketball games on asphalt, wearing skateboarding shoes.

My point here is not that I'm falling apart or anything, because in many ways, I feel like I'm doing great. That being said, I try not to play basketball without stretching and a pair of appropriate shoes. I also don't foresee many 10 stair handrail attacks in my future either. What my point is, is that learning about the human body is one of the best things I've ever had the privilege of doing, and that (just about) every day I am in awe of how this bag of bones actually works. Simple things, such as learning how to do a physical exam and finding where all the different lobes of the lungs are to be found and where to listen for the different heart valve sounds is amazing to me. It puts things like metabolic pathways into perspective, and enables me to stay motivated.