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Radiology is, much like law or politics, a career choice I would never make for myself but am nonetheless grateful that not everyone shares that attitude. I can’t imagine devoting twelve years of my life to school and residency just to sit in a dark room and play “what’s wrong with this picture” for the rest of my life.* It’s not that reading scans is an easy task, or that it doesn’t require a whole lot of training—even spotting basic fractures on an x-ray is a challenge for me—but I’m pretty sure I’d fall asleep after about ten minutes of staring at black-and-white images on a computer screen.

On the other hand, if said computer screen happened to be located in the neurology imaging center at the university hospital, I might be persuaded to change my mind.

The professor I shadowed in neurology last week was about five foot three and wore a bow tie and round spectacles. He looked as though he would fit right into a Sherlock Holmes story, bent over a bubbling array of beakers and test tubes.

When I arrived he and his team (five residents, two med students and a nurse) were in the midst of morning rounds and were discussing a patient they suspected of having Guillain-Barre syndrome. Part of narrowing down the diagnosis involved spotting an inflammation of peripheral nerves on a MRI; a difficult task in a brightly lit hallway on a small laptop computer.

“All right then,” the professor said, “Let’s take a trip down to space-mountain.”

As the chief resident explained to me on the way down, the neuro-imaging center, where we were headed to consult with an attending radiologist, was brand new and ultra-modern. The main light source was a wall of dark blue glass panels that glowed just enough to illuminate the room enough to see. Computer stations honeycombed across the floor, each with two sets of large, rectangular LCD screens. Each cubicle was divided from the next by wide, geometric partitions. The walls that weren’t operating as a light source were lined with soft, concave pieces of foam that I assume were designed to dampen sound in the room, although I’m still not sure why that would be important.

Overall it felt as though I had accidentally stumbled onto the set of a sci-fi television show or maybe a game of laser tag. Space mountain indeed. I’m pretty sure if I worked as a neurologist there, I would find any excuse to consult with the radiologists:

“Do you think this might be a brain tumor?”

“Dr. C there’s nothing there.”

“Oh, good to know.”

“This is the fourth time today you’ve been down here today for non-existent brain tumors. Don’t you have work to do?”

“That’s not true; an hour ago I was here for a non-existent subdural hematoma.”

“That’s it, GET OUT!”

* Of course now there are interventional radiologists who perform basic procedures and have a lot more patient contact in addition to spotting tiny, barely perceptible abnormalities on scans.

Classes started this week. As part of getting back into the swing of things, I’m procrastinating writing about my awesome neurology shadowing experience. In the meantime, here’s a neat article about a protein that destroys the HIV virus in rhesus monkeys. Which sounds so promising, but the article also points out that all the research was done as cell cultures, and not with actual living monkeys. I’m going to assume that the next step is to inject some monkeys with HIV and see what happens. Poor monkeys.

Warning: this post describes medical processes that some folks might find to be unappealing or “really freaking gross.” Just as a heads up.

Pre-medical folks are a special bunch. There aren’t too many people with whom you can have this interaction:

Me: Hey, Dr. P doesn’t have much for us anymore. Mind if I follow you around for a bit?

Graduated Postbac Working as a Scribe in the ER:  Sure. Not much going on here right now. Did you see anything interesting today?

Me: I got to watch them drain about seven liters of fluid from a guy with ascites.

Scribe: Oh really!? Man, I’ve been wanting to see that. I can’t believe I missed it!

The gentleman in question was a former alcoholic who reported having consumed somewhere around a twelve pack of beer every day for the majority of his life. He was utterly emaciated, skin hanging off a rail thin frame, with a stomach that was so distended with fluid he looked ready to give birth to twins.

We first stopped by his room with Dr. P in the middle of a sonogram. The patient was quite calm; he’d been through this whole routine before and simply wanted the doctors to drain off the fluid and be on his way. Dr. P asked about his drinking history and a previous diagnosis of liver failure (cirrhosis), and then gestured me over to his far side.

“Place your hand on the side of his abdomen,” he told me.

Gingerly–I had the irrational feeling that if I pressed too hard he might pop like a water balloon–I placed my fingers on the side of his swollen stomach. Dr. P tapped lightly on the opposite side of his abdomen, and, like a taut drum, I could feel the vibrations moving through the fluid in waves.

The liver is a multifunction organ, and one of its many jobs in to synthesize the proteins that help keep fluid in your blood vessels. In the case of this patient, his liver was completely scarred over from years of alcohol abuse and could no longer perform this function. This caused the fluid that was supposed to carry blood cells to all regions of the body to leak out of the vessels and accumulate in his abdomen. This condition is known as ascites.

“Patients with ascites have a lot of the same complaints as pregnant women,” Dr. P told us. “All that fluid starts to push on their other organs, makes it difficult for the lungs to expand downward so it becomes hard to breathe. Plus they’re carrying around all that extra weight.”

Half an hour later we watched a couple of residents disappear behind the curtain. Dr. P encouraged us, me and another postbac who was shadowing that day, to watch.

We peered our heads around the curtain to see that one of the doctors already had a needle and catheter inserted into the lower left side of the patients abdomen. This was to avoid the jumble of organs that exist on the opposite side of the abdominal cavity. Something hadn’t been hooked up quite right, and much as you might imagine puncturing a water-filled balloon with a yarn needle, fluid was spilling out over the doctor’s gloved hands and onto the bed sheets. Quickly she scrambled to attach the hose to a vacuum pump that the other doctor had positioned on the floor near the patient’s head.

“The last time they did this they got four and a half liters,” the patient told us.

“How much do you think we’ll get this time?” asked the doctor holding the needle. “I’m going to guess four.”

“Oh I think it will be closer to five,” said the patient. “You’re going to want to get a few more jars,” he told the resident seated by his head.

As it turned out they needed four containers for all of the fluid, nearly seven liters (1.84 gallons) of a transparent, yellow-green liquid of a similar consistency as urine. And there was more where that came from. By the time they were finished, the patient’s bowling ball-sized stomach had shrunk down to nearly normal size. The skin over the remaining fluid rippled and sloshed like a water bed.

The patient argued with the doctors to keep going.

“We’re out of containers!” one of them protested. “You’ve filled them all up!”

When we returned to the main station, Dr. P explained the risks in draining too much fluid from a patient with ascites:

“The minute they drain that fluid, it starts to fill up again. And that fluid has to come from somewhere; it’s going to drain out of his blood vessels. So even though he has all of this fluid accumulating in his body, he’s going to be dehydrated. It’s like dying of thirst in the middle of the ocean.”

The patient didn’t seem terribly concerned about any of this. “I’ll see you again in five weeks,” he told the doctors as they removed the catheter.

First up, I have two new ways that you, by beloved readers, can keep track of updates on this blog!

After a great deal of thought and a little bit of prodding from some good friends, I now have a twitter account: @cura_te_ipsum. You can follow me there, or, if you’ve not converted, you can see tweets on my blog just under my beautiful caduceus quill icon.

For the non-tweeters, I also added a link for those of you who might wish to receive emails when I update. (It’s just below the archive on the left there.)

I’ve just returned from my whirlwind visit back home, including one lovely day spent at the beach and a lot of bouncing from friend to parents to friend. I am now slightly tanner, much better rested and ready to buckle down and get myself organized for the upcoming school year.

Part of this process involves trying to secure my volunteer position for the year.

The town I’m living in is, more than anything, a university town. A good university too, with a medical school and a hospital and thus a very large number of people who need to fulfill their volunteer requirements at one of the few health institutions in the area. This makes securing a position with patient contact something of a challenge.

But no worries; our program began in the summer, which meant we have a jump start on all the little undergraduate premeds who will be descending on us in late August. We all cast our nets out early, and bit by bit my cohorts have begun to settle themselves into various positions in the hospital or the free clinic.

For myself, I took some time to weigh my options and eventually decided that I would like to volunteer at Planned Parenthood. A previous student from the program gave me contact information, and very quickly I was in for an interview. My job would be as an “options educator” on the Fridays and occasional Saturdays that were their “abortion days.” I would sit down with the women who were planning to have the procedure and lay out all of their alternatives; ensuring that this was the choice they wanted to make.

This job appeals to me on a number of levels. My background at a small college that was largely female has predisposed me to take an active interest in women’s health, particularly controversial issues like the right to choose. I also have a background in psychology, which seems well-suited toward the type of compassion needed to lay out a list of options to someone going through a stressful experience. Plus it would give me direct experience dealing with patients who need to make a difficult medical decision, and, according to the women I met with, I would be allowed to stick around and help out the doctors in the procedure rooms once I was done with the options educating.

Brilliant! Except for one small detail; classes. The earliest I could make it to the clinic on the days they want me would be a good hour after they needed me there. Which might still work, or might not but I haven’t heard back one way or the other yet. I’m sitting here, biting my fingernails wondering if I’m going to have to start this search all over again. Classes start in a week, and I would much rather be settled into a volunteer position than have it still up in the air. Not to mention the influx of undergraduates who will be descending upon us and quickly taking up any other possible positions in town.

I have two choices; I can cut my losses and see if there is another volunteer opportunity that will suit me in the next few days. Or, the way I seem to be leaning, I can keep trying to get in touch with them in hopes that there can be some other job I can do if the options education doesn’t work out. And hope that whatever that job is, it involves something actually related to medicine.

Who knew trying to help people out would be such an uphill battle?

Bumming around my parents’ house, I ended up flipping through a copy of Discover magazine and stumbled across an article on spatial neglect:

“In 1941, neurologists Andrew Paterson and O. L. Zangwill, working in Edinburgh, Scotland, published an account of a 34-year-old patient who had been hit in the head with a mortar fragment. The injury wiped out his sense of the left half of his world. Paterson and Zangwill described how the man ‘consistently failed to appreciate doors and turnings on his left-hand side even when he was aware of their presence.’ He also ‘neglected the left-hand side of a picture or the left-hand page of a book despite the fact that his attention was constantly being drawn to the oversight.’ The patient could play checkers but ignored the pieces on the left side of the board. ‘And when his attention was drawn to the pieces on this side,’ the doctors wrote, ‘he recognized them but immediately thereafter forgot them.'” (1)

The writer in me loves this idea; if there are parts of our brain that are responsible for simply noticing things around us, then how do we know that there aren’t obvious things that are simply not triggering those parts? We could all be running around in a world where there are places like the Leaky Cauldron from Harry Potter that all or most of us just don’t see.  How would we ever know?

Our brains are so good at giving us a whole picture the we often forget  it’s assembling pieces together that don’t exactly fit. Our perceptions of the world come with such conviction, but the science of the brain seldom validates this. When I studied learning and memory in undergrad we talked about how our minds eye will recreate a complete scene, but details–the color of a car, the position of a cup–will be rearranged without our knowledge. We will recall a scene as though it were recorded by a camera and never be the wiser to the flaws created by the assembly process. Even just seeing the world in real time is a compromise between brain and eye; we don’t notice the blind spot in our vision or register how often our eyes flick away from our main focus.

To me the brain is one part of anatomy that still holds so much mystery, not only because we don’t fully understand how it works, but because every new discovery has the potential to utterly change our perception of what it is to be human and to be alive.

(1) Zimmer, Carl. “The Brain.” Discover; Science, Technology and the Future. September 2010

Today I went out and bought a book.

I realize that this isn’t normally blog-worthy news, but to me this book, as well as the journey to purchase it, was my way of marking the end of chemistry and summer classes and the start of a well-deserved two week break.

Our final exam for general chemistry was last Friday. Grades were sent out today around three. I spent most of the intervening time checking my email like a junkie. Once I had my grade in hand, it was time to start on the million-and-one things-I-would-get-to-when-I-had-the-time.

Apparently the most pressing thing on the list was to get myself to Barnes and Nobles.

I have no self-control when it comes to book stores. The minute I walk in I want to buy the place. Everything looks good; the cheap shiny pulp novels, the somber looking classical works, even the cook books and travel guides. Never mind that I probably don’t even have time to finish the two books I was in search of, I just want to start in one corner of the store and work my way through until all the stories contained within the four walls are crammed into my brain. Today I felt like a starving person at a feast; so many delicious books to consume and only two weeks and twenty dollars to spend!

So if you’ll pardon me, I’m going to go delve into some fantastic writing and ignore that list of things I should be accomplishing now that I’m free from schoolwork for a bit. Cheers!

In between Nernst equations and voltaic cells (three guesses who had an electrochemistry exam today) I managed to squeeze in some shadowing at the ER. One of the professors who works with our program (I’ll call him Dr. P* for the purposes of this blog) is an ER and internal medicine physician and has been offering us opportunities to follow him around his various jobs. These include stints at the ER, a primary care clinic, and rounds in palliative care

ERs are starting to be called EDs more and more (no, not erectile dysfunction, emergency department) which makes sense seeing how they tend to be made up of many rooms, corridors and mini-departments. There’s a separate section for children, and another section for minor injuries for people who would probably never be seen otherwise. (EDs work by triage; most serious cases first, everything else later. A sprained ankle, even on a slow day, just isn’t going to make it to the front of the line as long as there are car crashes and food poisonings to deal with.)

I absolutely love shadowing. I love getting to wear my silly white coat, I love getting to watch the residents explain their cases to Dr. P, I love meeting the patients. The only thing I don’t love about shadowing is vomit, which seemed to be the order of the day yesterday afternoon.

Everybody has their thing, right? That one thing that, for no good reason, makes them want to run as far and as fast as they can in the other direction? For me it’s people throwing up. Which, I know I know, is something I’m going to have to deal with as a doctor no matter what specialty I go into; it’s up there with pain and passing out as the major signs that something internal is not going the way it should.

So I’m trying to think of it as a good thing that during my first ED shadowing experience there were no less than four patients who all had vomiting as their major symptom. One of whom, a miserable looking gentleman who was in a room front and center for most of my time there, retched his way through his entire stay in the emergency department.

I’m sad to say that I didn’t acquit myself as well as I would have liked. I’ve watched surgeries, seen mangled hands, a piece of glass in someone’s eye, but twenty minutes of listening to that man vomit and I had to excuse myself to sit with my head between my knees. How embarrassing! If I’d had any blood left in my face at all I would have been blushing through the rest of the shift. Even telling myself that it was as much due to dehydration as phobia (two cups of coffee and no water is not the way to start any medical experience, which I really ought to know by now) didn’t help; I felt like I had “WIMP” stamped across my forehead in big block letters.

In my defense, I did stick out the rest of the shift (and then some; I think all told I was there for three hours rather than the scheduled two before heading back to review for the exam) and managed to thoroughly enjoy myself once I was steady on my feet again. Perhaps it wasn’t precisely how I would have liked my shadowing experience to go, but I’ll chalk it up to day one of aversion therapy and hope that next time I can at least remain upright in my disgust.

* Confidentiality laws, common decency and the desire to someday practice medicine without my patients/employers judging me based off of what I write here has led me to take a few steps to preserve anonymity. Most of them feel pretty silly to me right now since 90% of my readership is close friends and family, but I’m trying to think big. And also avoid getting sued.

I promise there will a real entry tomorrow about shadowing and volunteering, but for now: It’s a bird, it’s a plane; no! It’s SUPER BABY!

::ahem::

Or rather it’s a genetic disorder that causes actual super strength. As of yet, there has been no signs of flight or heat vision, but I’ll keep you updated.