Pretty Interesting

Today I learned something pretty interesting. We are one week away from being done with anatomy. But that's not the pretty interesting something I learned about. We are studying cranial nerves one more time. Today I learned many things about cranial nerves, but the most interesting thing I learned is that the olfactory nerve, or CN I, rests on your cribiform plate. Your cribiform plate is a really interesting bone, because it looks like a thin cheese grater and just lays within your ethmoid bone. All these things, by the way, are in your skull, which is actually a ridiculous thing to look at when it's not covered in skin and hair. I'm still shocked that we have styloid processes, which look like sharp little toothpicks sticking straight down from around your ears.

Regardless, the reason why your cribiform plate is all holey is because the sensory fibers of your olfactory nerve pass between those holes to gain access to the outside world right next to your superior nasal conchae. Only cranial nerves I (olfactory) and II (optic) are directly in contact with your brain (all the others communicate with your brain stem) but only your olfactory nerve is also in direct contact with the outside world. That's right, if you really, and I mean really pick your nose, you can touch your brain.

But that's not even the coolest thing I learned today. THE COOLEST THING I LEARNED TODAY WAS.... from my mom, who teaches an essentials of clinical reasoning course. The fact that your olfactory nerve is the closest your brain gets to the outside world means that it can occasionally screw you up (and by screw you up, I mean kill you). So over the summer, a few people from Louisiana died when amoebas began eating away at their brains. The cause? They had been using Neti pots--a wonderful invention that lets you irrigate your nasal canal--filled with regular tap water... regular in that it had amoebas in it. Usually, drinking such water would just give you an upset stomach. But because the water was getting into their noses, and I mean really up into their noses, they ended up getting the equivalent of an upset stomach in their brains.

BAM! My mind... figuratively BLOWN! Not slowly eaten away by protozoans.... No. BLOWN! And that's why anatomy is interesting by itself, but it isn't fascinating until you make it clinical.

"Pregnancy is not a decision to be taken lightly"

During one of our clinical correlation lectures for anatomy, the guest lecturer said what lies below. I thought it was interesting, so I've provided it here:

"At term pregnancy, 50% of CO goes to the uterus. 500-700 mL course to the uterus/minute. The myometrium continues to contract and the bleeding is forced to stop.

The #1 cause of maternal death is due to embolism (20%). Hypotension, Hypovolemia, Shock (13%). Hypertensive disease leads to (13%). Pregnancy is not a decision to be taken lightly, there can be a lot of problems. Uterine atrophy (the blood vessels in the endometrium are incapable of contracting) is the number 1 cause of obstetric hemorrhage."

Makes you kind of grateful that someone would risk her life to create yours....
Is it Mother's Day yet?

Bioethics Self Challenge: How Ridiculous Can I Get?

Well, after challenging myself to write something more ridiculous than that one time when I wrote, "I think we can assume that this family is evil," I wrote something more ridiculous in the following hour. For context, I will say that we have to discuss health care issues using principles of biomedical ethics we have read about. I would elect to only read the bold, but sure, you can read everything else too.

Should it be legal for people to buy organs for transplant, if they would not be able to receive an organ by waiting their turn through the national database? 

This is an issue that involves Justice. Essentially, if we allowed people to buy organs instead of organizing everyone onto a wait-list, we would be defining wealth/capital as a relevant property. Relevant properties are defined as conditions/things "that persons must possess to qualify for a particular distribution" (243). In this case, "particular distribution" refers to organs for organ transplantation. As much as I would like to say I know what the relevant property for currently receiving health care in America is, I do not have a full enough understanding of health insurance to posit more than a few tentative ideas.  

Oh god, and then there's like three different main types of health care, so I should not begin to discuss this.  

Regardless, I think that changing the relevant property/requirement for receiving organ transplants is antithetical to the way medicine wishes to be practiced in this country. I think this is why less than 20% of the physicians surveyed thought it would be okay for people to buy organs that they may not otherwise receive. It is unfortunate that some people may not receive organs, but if it is something that is going to happen regardless, this grave misfortune should befall everyone equally. 

I also believe that changing the system into a monied one would simply make the process of organ transplantation much more complicated. 

More practically, it also feels wrong to treat transplantations in this fashion. I would argue that by failing to keep justice equally distributed among all persons, you are allowing maleficence to occur. Example! Let's say child Batman and child Spiderman both need liver transplants. Well, little Bruce Wayne (Batman) has really rich parents while orphaned Peter Parker (Spiderman) has only his lower middle class aunt and uncle to look after him. Many arguments have proven that both Batman and Spiderman are of around equal importance to society later on in life. Yet, had this hypothetical situation occurred, and if organs were doled out in accordance with payment and not according to wait lists, little Peter would not have made it. 

By changing the way the system works, and by allowing a subgroup of people to have more power in the system than others, you are creating a social inequality around something as serious as life and death. With great power comes great responsibility, and I do not think that anyone with an ethical mind could easily approve of this level of injustice.   

References:
Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009.197-199

No Duh Aristotle

Sometimes bioethics can be really dumb, and yet so disturbingly profound.

No, that last half is profoundly sarcastic.

Here is a fun quote from our Bioethics text:

"Common to all theories of justice is a minimal requirement traditionally attributed to Aristotle: Equals must be treated equally, and unequals must be treated unequally."

NO. WAY.
I think my brain just exploded from the complexity of that statement.


But to be serious for perhaps a paragraph, I really enjoy bioethics. I miss writing things out. Also, it's fun to posit ridiculous arguments. However, I don't know if I'll ever write anything more ridiculous than the following sentence I wrote for a discussion on vaccinations:

"I think we can safely assume that this family is inherently evil."
So get your kids vaccinated! 

Sexual Tension: It's Real

Direct from my notes (highlighting added):

"The female sexual act consists of arousal, plateau, orgasm and resolution. During the arousal or excitement phase psychogenic stimuli, both sensory and imaginative, and vasodilatory changes (increased blood pressure, skin flushing, engorgement of clitoris, vagina and labia) increase sexual tension."

Sexual tension actually exists?! I'm learning so many new and fun things in reproductive physio.

Sperm do WHAT?! oh yea, and Birth Control is Great!

I generally don't like to think about sexual reproduction. I mean, during mandatory sex ed in high school, I tried my very hardest not to pay attention because A) gross and B) I thought it would never apply to me.

But I've "matured". I've rarely giggled or gotten grossed out while reading over repro notes. Nevertheless, I've learned some things that I'm surprised I didn't know and things that are incredibly disgusting. For example: Birth control pills actually stop ovulation and sperm can live in your fallopian tubes for 1-2 days. What? and OH MY GOD THAT'S DISGUSTING.

But back to birth control, I don't know how I thought birth control worked, but I assumed you still ovulated. I guess I thought it somehow made egg fertilization by sperm (that can survive for 1-2d inside of you) impossible. But it literally stops you from ovulating.

So what's all this hullabaloo about birth control in the news? I can kind of understand why people are against abortion--wait, no, I can completely understand why people are against abortion. I can't understand why people are enraged that birth control is used in our society. It's not like you're actually hurting germ cells, which some people insensibly think are human (what would a haploid person look like? something Picasso-esque maybe?). And it's not like birth control pills are actually expensive to manufacture. Indeed, the advent of the pill probably reduced health care expenditure significantly, considering how expensive babies are.

I feel like there may be a lot of indirect cons to taking birth control*, and there probably could be a lot of scientific study into how the birth control pill changes human physiology... but I think everyone should agree: the pill is a far better choice than abortion.

*The estrogenification of our drinking water, the unnatural changes in female sexuality which increases the chances of sterile mating pairs, etcetera...

Ancient Medicine

I love physiology. It's a fun, and for me--a relatively straightforward--course. A lot of my fellow students have objections with the course director and primary professor. He is a very energetic old person and I personally like his notes, which is how I judge every single one of our professors:

If I can read through a person's notes and retain most or all of the information I've just read, that person makes great notes. You'd be surprised how many professors suck at this.

Still, he doesn't lecture off of power point presentations, which is the norm for almost all of our professors. Instead, he draws on a jerry-rigged overhead projector that is connected to the giant screen in Rhoades Auditorium. I like this method a lot, actually. It makes class feel less like a lecture, and slightly more interactive, although I know it isn't.

Regardless, sometimes you end up looking at things that have questionable content.

Like today, we were talking about the fetal circulatory system, and our professor found a mistake in the diagram--a diagram that he had admitted taking from a textbook published in 1964 and using for at least thirty years, if not longer. Below is the diagram (in red, my added comments):

Awkward...

Why haven't we updated to something more current? Or maybe something with color? Still, I guess it's comforting to know that the human body hasn't changed that much in fifty years.


But WAIT! Hold up... there's a mistake in this diagram. I think he said that the error involved the V's... they are supposed to be villi, not veins... but okay, so let's say this actually is a mistake... so people have been learning the wrong thing for 50 odd years? 


Medicine! It's an Imperfect Science!

HaHaHaHaHahahahahahaha.....

Cervical mucus.

I am not mature enough for physiology right now.

The Rhythm Method

So fun fact: the rhythm method is an actual form of birth control. I was shocked, too, mostly because it seems like it's the preferred birth control method of Republican Presidential Candidates. 

The basic premise is that you can't get pregnant on certain days of your menstrual cycle. Okay, several problems:

1. Gross. You mean to tell me that married couples will talk about menstrual cycles in the context of not wanting to get pregnant? I assumed that men only talked about menstrual cycles when they were trying to get their wife/girlfriend pregnant. I guess not. Once again, gross.

2. How do people even understand the menstrual cycle anyway? It's not impossible, but it's one of the more complicated segments of human reproduction, as evidenced by the fact that our physio professor has now been talking about the cyclic nature of hormones and metabolism for the last twenty minutes… and we're not even close to done yet. Furthermore, yea, menstrual cycles are pretty constant, but they can change. So using the rhythm method could still get you knocked up if you're planning on avoiding sex five days before ovulating. SURPRISE! You started ovulating early. Here's a baby.

Basically, it's complicated, so why would you tell people that they need to figure it out for themselves instead of just giving them birth control?

3. And finally... What the hell?! The rhythm method?! That is just so ripe for making fun of! It feels so much a euphemism, and not something that is actually scientific, that I can't take discussion of it seriously. Public health. Ridiculous.

Additional fun fact: we have started the reproduction portion of our basic science courses. I am scared.

Spring Forward

It is really nice outside today! Sixty-six degrees, sunny, not very windy at all. I had to drive to Walgreens to get some allergy relieving eye drops, and I put the top down, and it was heavenly. Unfortunately, I have to stay inside pretty much until I pass out from exhaustion because tomorrow is our final biochemistry exam. And I am failing biochemistry.

I kind of wish I could argue with someone about my specific case, so I will argue with you. Inarguably, I am doing poorly in only two classes: Anatomy and Biochemistry. For all my other classes, I got my act together, learned how to study, and am passing all of them. Except for Anatomy and Biochemistry. I've spent probably an hour looking over my test grades in both classes, figuring out the bare minimum I would need to get on the remaining exams to pass. And this is where life gets sad, because all my test grades in both classes fall into the C to B range... except for the first two in both classes. If I could retake the first two exams, after learning how to study properly, I probably wouldn't be freaking out so much right now. I'd probably eat dinner outside, enjoy the first truly wonderful day of Spring.

Actually, my above admission isn't entirely correct. For Anatomy, yes, all my grades after the first few were in the C or B range. In Biochemistry, I seemed to do really poorly only for one person's exam. He taught two, noncontinuous, portions of the class. When I averaged my grades based on who was teaching the material, I found that for one professor, my average was around 53%. Should I blame the professor? Probably not, but it's tempting when I present statistical evidence that I couldn't learn from that man.

So now I have to get a 97% tomorrow to pass the course. I've gotten 100% before, when I really needed to. I'm hoping that that will help ease my anxiety. I also know how to study finally, so that should help as well. But there's always a large chance that they're going to ask a question you didn't think would be important, or ask it in a way that is much too confusing. So no matter how well prepared I am going to feel--and I intend to feel really prepared, there's always that chance that I will get a 95% and that won't be good enough.

Meanwhile, in a hypothetical perfect grading system, I've come up with a more idyllic plan to promote learning: If a student should get below a 50% on an exam, something I've done about four to six times over the course of all the tests I've taken here, wouldn't it be better to have the student retake that exam? Or have them complete a take home exam? And then the score could be ameliorated to something, still failing, but more beneficial for the student's psyche, say a 60 or 65%. In this way, wouldn't you kind of be forcing the student to relearn the material? Yes, failing should be punished. We can't have our doctors being daft. But by just giving me a 38% on an exam, I have no motivation to ever relearn that material. Quite the opposite really, because I am now so traumatized by the anatomy of the lower extremity that I care nothing about it.

As much as I disagree that all of this information is important, some of it is, and I won't know which will be important until I'm actually out there, practicing medicine. So wouldn't it be better to have students look at material again, instead of consigning them to spend a nice day freaking out way too much about something that, in the end, might be impossible to actually achieve?

Selfish Diabetic

Today when I woke up, I woke up with a headache. I cursed my decision to have chips last night as I was going to sleep. Too much glucose. Not enough insulin. I surveyed my skin and noticed I had developed those annoying lines you get from your bed sheets all over my arms. Peripheral edema. Yes. The hyperosmolarity of my blood would have caused an increased retention of fluid in my renal system. I checked my face in the mirror. Puffiness was present around my eyes, though perhaps that had occurred from not sleeping enough.

Fourteen minutes to class.

The oxidative stress of prolonged hyperglycemia on the body can cause diabetics to feel as though they need to sleep more. I have been taking an unnaturally large amount of Vitamin B throughout my medical school year. I do not know for sure if Vitamin B helps relieve oxidative stress--in fact, it very well might make it worse--but it's one of the things diabetics need to replenish according to Walgreens Pharmacies, so I take Vitamin B. I no longer always require eight hours of sleep, although sometimes...

Eight minutes to class.

Objects are falling into my backpack with little thought. Every day is more or less the same. One binder. One laptop. Always the same, though learning is always a little different. Finding my glucose meter, I decide to test. Sometimes I will be much higher than I think, will not take insulin, and spend the entire morning in the 200s. Glucose is 61?

So then what caused the edema? What caused the headache?

I think about my food intake at dinner as I guzzle some fruit snacks before leaving my apartment. Two minutes to class. What could my renal system have been doing while I slept? What about my endocrine system? What was my body doing that caused me to wake up the way I did? Exhausted? Edematous? But with a high core body temperature and a headache?

I wonder all these things and sometimes feel so close to drawing all the lines together and truly understanding how physiology interplays with biochemistry, then anatomy, and how all of these things affect my life. It is frustrating, but it is exciting--as if someone was carefully guiding me to enlightenment, nirvana, without my knowledge. Understanding why my body does the things it does will make me beyond happy. It will make me a fully realized human being.

This leaves me with a few thoughts: Why are there otherwise healthy people in medical school? And how can the few medical students I have met who confess they are only in this for the money... how can they study at all?

Library Tang

I have tentatively begun studying in the library. Several things about it bother me to no end, namely, actually, just one thing: the lighting. But during partly cloudy days, it's not impossible to concentrate in the place. Still, I like to keep the affair as informal as possible, choosing to study not at tables... (or shudder... cubicles), but rather in large, low lying chairs that are almost like loveseats in width. I was minding my own assignments, attentively listening to the absolute silence that is graduate school students studying, when a shuffling of feet, not two, not three, but six, six feet! caught my easy to displace attention.

So there I was, staring at three people I did not know, moving at erratic paces, but all together, in the same general direction, through book shelves and behind desks, and they seemed to me very much like any one of the many species of Tang that move along coral reefs. This simile is only mildly appropriate once you realize that Tang are a part of an even larger subclass of fishes called Surgeonfish. Regardless, I wonder if over time the library will remind me of other wonderful places I have been.

The Human Model

You can learn a lot from patients.

Sometime last week I went over to the Hospital of Veteran's Affairs to volunteer at a clinic. The clinic is submerged into the homeless shelter at the VA. We were instructed to take patient's histories, a skill we all learned as part of our Essentials of Clinical Reasoning course. I was uncomfortable at first, but it's always surprising how human-like human patients can be.

Regardless, one of the people I saw was a fellow diabetic. While the people running the show scrambled around looking for an appropriate test meter (because I do not know how to use the really fancy ones; OneTouch meter's are always full of extraneous options that I can't work), I got to talk to the patient.

Somehow we got onto the topic of significant others, and the diabetic had some wise words to say about the ills of domestic violence. He said two really touching things. The first was a rather hilarious anecdote about the only time he had hit a girl. It was in high school, and he had slapped his girlfriend, thinking to himself that she was acting like a b*#$!. Well, he had not been counting on being held accountable. Coming home, he was greeted by his seven sisters and his affronted girlfriend. They did more than "explain" why his behavior was out of line.

Second thing: he expounded on why women are ultimately the more important gender. I was fairly impressed, and I keep thinking about what a character that diabetic was. I want to write more about him, or at the very least, write down what he said so I can tell my own kids how to avoid domestic violence in relationships. Honestly, I don't think he learned anything from me. But I ended up learning a lot from him.

Another strike against paternalism. Perhaps the doctor-patient relationship is more like a symbiotic relationship, where both groups are made better through their interaction. Regardless, I feel like I could write a chapter on the character that this patient presented, even if briefly--even if less than twenty-minutes.

This is why I went into medicine.

I want to learn more about the human condition. I can't write about people if I do not understand them, first. Certainly that's not only the reason I am in medical school. But for the part of me that is a writer, that's all the motivation I need.

On Call

So my friend just called me to tell me that her twelve year old roommate has been really sick for an entire day. I got to run a differential! So, patient has had nausea for a day, with intermittent vomiting and diarrhea over the same period. Abdominal pain crampy. Pain is also diffuse and not localized to the RLQ (if it were, suspect appendicitis). Patient is afebrile (almost entirely rules out appendicitis). Most likely diagnosis: considering the age of the patient, most likely cause of pain is gastroenteritis, or stomach flu. Patient is advised to stay hydrated and replace lost electrolytes. It is recommended that patient also go to school tomorrow if she feels any better at all.