So much for one major religion, then.

Examine your prejudices.

So I guess I can't be Catholic. The Vatican recently released "On the Dignity of Persons"--in Latin, of course, to make it sound cooler--in which Cardinal Ratzinger (he'll always be Cardinal Ratzinger to me, because it sounds so much more appropriate than Pope Benedict...which just sounds like a sacreligious breakfast dish) decried stem cell research and the morning-after pill as the harbingers of the end times. Well, not exactly, but he called them both mortal sins, ie Very Bad Things.

Here's the thing. The morning after pill prevents implantation of the (potential) embryo, which at that point is (if anything) a collection of several cells--like, literally less than 100. (See, Dr. C, I paid attention during your embryology lectures!) It doesn't kill it. It keeps it from glomming onto the uterus, which is what happens more than 50% of the time anyway. It isn't abortion (which I'm also not saying is wrong...but that's a whole 'nother kettle of fish), so even if you're opposed to abortion, you don't have to be against the morning-after pill.

I honestly think every woman who's begun to menstruate should have the morning-after pill, or a prescription for it, in her medicine cabinet (well, actually in her dresser drawer, since the temperature fluctuations and humidity in the bathroom could screw with the drug). Am I saying everyone should be out not using contraception? C'mon now, don't you know me better than that? Sometimes contraceptive methods fail. Sometimes the condom breaks. Sometimes you realize the next morning that, yeah, you were both really drunk and didn't use one, and after saying a few mea culpas and vowing never to be that irresponsible again, you need something else to do. In short, life happens, ergo shit happens.

But (hold on while I get out my soapbox...) EVEN IF you're one of those who thinks heathen young women having sex out of wedlock should have to "face the consequences" of their actions (yes, person purportedly so concerned about an unborn child's wellbeing, let's think of the kid as a 'consequence' rather than a person--do you not see the intrinsic cognitive dissonance there? And let's not even get me started about the heathen young men who get off scot-free, morally speaking, because boys will be boys...) those aren't the only people who use the morning after pill. Here I will insert a

**Self-disclosure alert**

I have used the morning-after pill. If I were ever in the same situation again, I would use it again without hesitation, even knowing the side effects (it made me so nauseous I had to go get another prescription to replace the one I'd urped up, as well as a few hits of promethazine--ie Phenergan, an antiemetic that had the nice fringe benefit of making me tired enough not to care if I was feeling vomitous). I was raped my freshman year of college. September of my freshman year of college. The only thing that could have made it a more fantastic start to my academic career? If I had gotten pregnant. I realize most people dismiss this as The Extreme Example, but honestly it's not as rare as you'd think; 25% of college-age women experience rape or attempted rape at some point during their schooling.

If my God/Divinity/Ultimate Reality required a young woman to carry her rapist's baby, I would look for another one. Or maybe I'd talk to Her directly and see what She had to say, rather than getting it secondhand from a lifelong-celibate male (ahem).

Fears and Vindication

Finals are upon us. A time of trepidation, of fear, but also of vindication.
The holidays are also upon us; likewise, a time of mingled despair and delight.

What am I afraid of? Unreasonably afraid of?
I am afraid of failure, but more than that I am afraid of mediocrity.
Less existentially, I am afraid of food poisoning--I've only had it once, but it left a lasting impression. Salmonella and e. coli especially.
I am afraid of never finding "the One"--the person to spend the rest of my life with.
I am afraid of flying.
Spiders.
Failing medical school and having to live in a box under a bridge.
That I will never be truly happy, because I'll never really know what that even looks like.
That everyone else knows what they're doing, and I somehow missed picking up the secret instruction book that the rest of the world is reading from.
Cancer.

What am I proud of, vindicated about?
That two of my finals are over, and I passed them.
That I've survived this long in one piece (it's been a bigger task than you might think).
That I'm blogging again.
That for the most part I manage to prevent myself from indulging in sophomoric navel-gazing like this.

What about you?

I know I am a medical student because

I get nearly 100% of my fluids from caffeinated beverages.

I have gone out drinking after an anatomy exam...at 11 in the morning.

I spend more time on my cadaver's body on a given day than I do on my own in roughly a week.

I have skipped class...in order to study.

I have learned so many mnemonic devices, I have trouble keeping them all straight (and they all have to do with drinking or sex--especially the ones I've written for myself).

I can now eat a meal while discussing dissection technique (and in fact did so on Sunday night...thanks for the dinner and calvaria-removal talk, Dr. Ginder!)

I have realized that while showers can wait, and laundry can wait, anatomy waits for no man (or woman).

I have had dreams about the brachial plexus.

I have come, after almost a semester of medical school, to realize that I have more to learn than I could ever have previously fathomed. This is both very humbling and terribly exciting.

I don't wanna.

Anatomy exam 2 came and went. I did better on this exam than I did on the last one, which pleases me, but not as well as I would have liked (of course, anything less than a 100 is 'not as well as I would have liked,' given my inherent OCDish-perfectionist tendencies, so this is somewhat less than surprising). So the limbs are done. And the pelvis, and the perineum. On to the head and neck! Onward and upward to the Circle of Willis, I say! And on to a biochem quiz!

One problem.
I don't wanna.

Woke up at 3:30 this morning, couldn't get back to sleep, and I don't wanna. Don't want to go to my PCP preceptor's office this afternoon; don't want to study for my biochem exam (though I have been, don't get me wrong); don't want to learn physiology or biochemistry this morning. And yet I will do all these things. Because that is what adulthood in general, and professional school specifically, is about. Mostly doing things that you're excited about, but on some days, when you just want to stay in bed and look at cuteoverload.com or maybe watch an Eddie Izzard DVD or finish that painting you've been putting off...going into lecture or lab anyway. Bleargh.

When do political issues become medical issues?

And I'm not even talking about health plans here. I'll leave aside for a moment tax credits vs. Medicare-for-all vs. universal employer coverage (which, by the way, still isn't analogous to universal coverage). I'm thinking specifically about the recent outcomes of Prop 8 in California (to ban same-sex couples from getting married), and of the Arkansas vote to prevent unmarried couples, gay or straight, from adopting children.
Now, you might say it's a good thing for children to be raised in intact homes. That's true. There are, however, intact and loving homes that haven't been marked with the state's official seal of approval (ie, a marriage license). Add to that the fact that the parents in some intact and loving homes, by virtue of legislation like Proposition 8 in CA, can NEVER become married--and the fact that various agency representatives in AR have said they basically intend to look the other way on the marriage issue "as long as they ain't queers or nothin'" (OK, so I've dramatized a bit) and you have a message of hate masquerading as concern for child welfare, which makes an already regrettable attitude downright despicable.
Am I saying this on account of the fact that I--at some point in my adolescence--'caught the gay?' Well, yeah, in part. But I'm also saying it because I know gay parents who have only managed to be legally recognized as the parents of their offspring through processes like second-parent adoption, and this sort of law threatens the ability of my tribe to create families. So what's second-parent adoption, you ask? Essentially, Mary and Alice are a couple. Mary gets artificially inseminated, maybe with Alice's egg to make the experience more equally 'shared'--but also a damned sight more confusing. So, Mary gives birth to the baby and is thus listed on the birth certificate. But, lo and behold, there's only space for one parent of each sex on the birth certificate, so Alice is S.O.L. until she secures a second-parent adoption, which establishes her as another mother. OK, I lied, it's not actually that confusing--just frustrating and lame.

So let's say (Goddess forbid) something happens to Mary, and there's no adoption, and no marriage. Well, if Mary listed Alice as the child's next guardian, it's all OK (well, not really, because if Mary's parents don't like it, they can contest it in court and in Arkansas chances are they'd win) and the right person ends up with the kid. But if Mary hasn't made a will? If she hasn't been thinking about her mortality, if her death wasn't anticipated, and she accidentally steps out in front of the 29 bus some morning? It would be nice to say that Alice, as the child's de facto other mother, would automatically get custody...but it would only be nice to say, because it wouldn't be true. Mary and Junior are both injured in a car accident and both incapacitated? Guess what--if they live in the wrong state and Alice hasn't officially been invested with healthcare decision-making power for her partner, Alice can't legally make medical decisions for either one of them.

That's when political issues become medical issues, and why a physician with the best interest of the patient at heart must be aware of both.

Who says there's no fun allowed in med school?

Quotables from the most recent set of lectures

"You can in fact exercise your pubococcygeus muscles. There are exercises called Kegels, and the best thing about them is that no one knows you're doing them...you can stand at the podium and contract them as you're lecturing, for example, and no one has any idea." --Our very funny anatomy prof with an AMAZING British accent

"There are many theories as to why humans evolved bipedal locomotion. To see cheetahs in high grass and avoid being eaten; to be able to wade into water to fish without drowning; to be at the right level to harvest grain. My personal opinion is that it evolved to enable us to drink Bud Light. Try drinking from a can while on all fours sometime...maybe after you've had a couple already. Very difficult. Hence, bipedalism."--Another anatomy prof in a stunning nonsequitor

(On trans fats) "What did you guys have for breakfast? Any McDonalds? How about a glazed doughnut? No? What did you have?"
Student: "Cottage cheese and a bagel."
Prof: "Man, you guys are boring. I knew when I didn't get any questions after the midterm that you were low-key, but...anyway, there are about 5 grams of trans fats in a bagel, 10 in a McDonald's McMuffin. You're only supposed to have 2 grams, max, a day, so after one McMuffin--bam--you're dead for a week."

Limericks (no, not from Ireland...less dirty)

For Table 10

There was an anatomy table
That quite simply did not seem able
To dissect with the speed
The professors decreed;
in the end, the stress made them unstable.


Standardized patient--failure

I entered the room with a grin,
Asked the patient, "So how have you been?"
HPI and exam,
then I thought, "oh g*ddamn,"
because I forgot to foam in.


Upper and Lower Limbs

I've been studying muscles for weeks,
lumbricals down to gluteal cheeks.
Can't learn one more insertion;
Such crazy exertion
can't help but reduce me to shrieks.


Histology

I can use a microscope well.
Preparing a slide? That's just swell.
But then point out some bug,
and I'll say with a shrug,
"I can tell you it looks like a cell."

Pelvis and perineum, you say?

Yes, sex has officially become boring. Not just because it's been reduced to memorizing the branches of the pudendal nerve, the difference between the corpus spongiosum and cavernosa, and the inferior hypogastric plexus. No, (oversharing alert) I've also started to feel the effects of the massive quantities of Zoloft I'm taking, which means that while I'm not having panic attacks every day, nor considering jumping onto the Metrolink tracks, I am also somewhat lacking in the libido department. Granted, looking at all the photos of rectovaginal fistulas and elephantiasis of the scrotum in anatomy lecture may not have been the most...titillating, either.

Anne, I hear you saying, you write about anatomy all the time. We almost never hear about physiology or histology; sometimes you write about biochem or a selective, but rarely. Is anatomy really that big of a time-suck? Does it really weigh that heavily on your mind? To which I answer: yes, dear reader. Yes, indeed it does. And the bitch of it is, you really do need to know it. It's not like, say, some of the more esoteric histology and biochem lectures, where one could argue that the majority of physicians aren't going to need to know about post-transcriptional modification of mRNA in their practicing lives (if ever...ok, maybe at a bar trivia night, but then again, there was never a damn question at Lew's trivia night--In KC--that I knew by virtue of being a hoity-toity neurosci/German studies major. Mostly it was about sports, and weird/arbitrary 'pop culture'--so you know my scores were always in the crapper. Add to that the fact that it takes one--count it, one--Bud Light to knock me on my ass, and there you have it: the reason I never won 50 bar dollars. In Ithaca, on the other hand, the questions were of...ahem, pardon me while I have a snobby, elitist liberal moment here...a higher caliber, and the Telluride group always cleaned up nicely. I spent a bare minimum of my own money at The Chapter House. Good times).

In the course of my studying, I have come across a handful of words that I've fallen head over heels (make that cranium over calcaneous) for, and here they are:

acetabulum: where the femur (thighbone) articulates (connects) to the innominate (hip bone). Sing it with me...the thigh bone's connected to the acetabulum...

infundibulum: a cavity opening either into a tube or into the outside world; there is an infundibulum in the right ventricle of the heart, one in the fallopian tubes, and one in the shaft of every one of your little hairs.

Don't they just sound like Harry Potter words, like mad incantations? Can't you see Hermione Granger shouting, "Infundibulum!" and laying out a Death Eater? Can't you see what a huge dork I am, augmenting my dorkiness further by referencing a children's fantasy series in relationship to anatomy?

poetry alert

Memento Homo Quod Cinis Est
(Remember, O Man, that you are Dust)

Standing in the dissection suite,
scrubbbed and gloved
(as if latex were protection
from the knowledge of one's own mortality)
I map out veins and tributaries,
tease out secret nerves
and contemplate the possibilities
of the awful glory of God
made manifest even here.

Skinned one,
Dismembered kindred, I too
have had someone
saw through my pelvis; I have been
the lovely assistant
split in two,
still smiling as the blood begins to flow.
I too have had someone finger my heart,
probe the chambers and valves,
Squeeze it like a child's toy and not
the seat of the soul that it is, that delicate tether
Binding body to earth.

Today we skinned your left hand,
removing a lifetime of jingled quarters
and turned pages;
today we stripped away
the last time you held your wife's face in your hands,
those familiar caresses as much a part of you
as that thin skin,
those ridged white gloves.

Despite the things
that have been lost,
the loves and longings wrenched
from between my fingers,
I am still able to hold on; am not yet
so far beyond the grip of grace
they might not be restored, or found anew.
I covered you, washed my hands, and as I washed
said a small prayer of thanks
for my small life,
and yours.

Stigma

Today in one of my 'selectives'--sort of "extra" cool little classes that you take on the basis of interest rather than...how do you say?...requirement--we had several presenters speak on mental health services in St. Louis, and on the failings of infrastructure and policy in the American mental health system generally. There was also a discussion beforehand (with the 'coursemaster'--I love that term; it makes me think they should be wearing wizard robes and brandishing a staff, shouting, "Behold, I am the coursemaster!") on the stigma associated with mental illness, and the extent to which that's a barrier to people who would otherwise benefit from mental health services.

Stigma. The word itself means 'mark.' "Stigmata" are the markings of the crucifixion; someone with a contract on his head is a 'marked man'; Cain was stigmatized, marked, after he killed his brother Abel. Believe it or not, there wasn't always such a stigma attached to madness in Western society (I say madness only because that's what it was called back then; there are no medieval texts on 'mental illness.' Trust me, I wrote several loooong papers on this in the process of getting a German lit degree in my former life as a student of the humanities). Sure, some societies still thought that the mentally ill were possessed by demons, but an equally probable explanation was that the individual had been touched by God. Craziness was actually a good deal better tolerated then (by which I mean during the Middle Ages/Renaissance--read Michel Foucault's fabulous book "Madness and Civilization" to see what I mean). Then again, everyone and their dog had neurosyphilis back then, so maybe the bar for psychiatrically normal was a little lower, too.

Now, of course, psychiatry works with the laudable goal of alleviating human suffering; it also (sometimes) works with the much less laudable goal of making everyone maximally productive and optimally functional within the confines of a society that I think most enlightened and sane individuals would agree is inherently crazy-making...and while there have been some shifts in attitude even in the last twenty years (celebrities can speak frankly about substance abuse problems and battles with postpartum depression; mainstream sitcoms feature characters on antidepressants) there's still a lot of work to be done when it comes to acceptance of mental health issues.
The last time I was getting my car fixed (I always take it to the same shop--the owner is the father of a friend I had in elementary school) I mentioned I was going to medical school, and that I hoped to become a psychiatrist. My friend's dad took this as an invitation to expound on the virtues and failings of psychiatry as an institution, and more specifically the ways he saw psychiatric diagnoses as misplaced--as attempts to excuse moral deficiency or dodge responsibility:
"I think bipolar disorder is just another way of saying someone doesn't want to take responsibility for their actions...that they're immature."

I literally didn't know what to say, and not just because I'm (medicatedly) bipolar myself. It's that sort of attitude, that refusal to recognize that a disease is no less real because it manifests in the brain rather than in the pancreas or heart, that makes medical faculty and students deride psychiatrists as "not real doctors." That's the attitude that keeps a man from going to his physician with his suicidal ideations, for fear of being thought weak; that makes someone push and push and push themselves, a la Sisyphus, to run the mental equivalent of a marathon without pausing to consider that their anxiety or depression is the mental equivalent of a broken leg, and needs treatment equally as urgently. All right, I recognize that last sentence was awkward and clunky, and that's my cue to go to bed.

Let the games begin!

In high school, I wasn't sporty. In middle school, yes, and in college, but not in high school.

I had band letters and academic letters (and debate) for my letter jacket, but no sports. So it struck one of my teachers as particularly funny when I described finals as "my Olympics." Seriously, I practically ran around the school in a tracksuit and headband emblazoned with "pi"--shouting, "1,2,3,4, I know what adrenal glands are for! 5, 6, 7, 8, and who won the Lincoln-Douglas debate!" DORK. Then as now, though now I am comfortable with and embrace my dorkdom. The popped collar and Chanel handbag contingent can be who they are, but I am who I am--someone who thinks enzymes and cell structures and clotting factors are pretty damn cool.

So, kids, I'm about to go do the first leg of this week's Olympic marathon--that is, midterms. MFM (which you may remember as "biochem, but interesting," not least because the prof is awesome) is this morning, in approximately half an hour. I've studied, as Holden Caulfield might say, "like a bastard," and I've gotten a good night's sleep (OK, a slight exaggeration, seeing as I never have 'a good night's sleep,' but as good as I ever get) and had a hearty oatmeal breakfast, and I'm wearing my lucky shirt. We do what we can. Let's see who comes out on top--me, or 100-odd questions about enzyme kinetics and metabolism. For once, I'm actually NOT nervous. But that could very well change in, say, 25 minutes or so.

A standardized test?

We had our first standardized patient session today, something for which I felt woefully unprepared. It was supposed to focus primarily on communication skills and history-taking (right up my alley, no? You'd think...) but there was the addendum of the physical exam that made everyone a little...squirrely. Nervous, edgy, though of course everyone does their best to hide those things (I can't be the only one hyperventilating, can I? Of course, maybe I can). Some of the things we were supposed to know how to do hadn't been covered in our small groups at all; the best summary I can give of the 'musculoskeletal exam' I was taught would be, "Have them move things around and see if it hurts. Then you move them around and see if they hurt. Also, there are lots of bony landmarks you should be aware of, and everyone hurts their ankles and knees at some point so you should probably know what to do for those sorts of injuries." Standardized patients, by the way, are actors who are paid to come in, sit in exam rooms, and serve as fake patients. They give the histories from the scripts the medical school provides; they act out all the physical findings you're supposed to see (limps or tenderness or stiffness or whatever). The woman today was quite convincing; I found myself actually worrying that I might be hurting her. Some standardized patients really get into it deep, from what I've read: here at this Slate article I learned there are even those who let medical students try out their newfound pelvic exam skills (there's. not. enough. money. in. the. world. to make me do that).

We weren't even being graded, per se, on this encounter; I really shouldn't have been nervous. But we were kept standing outside the little exam rooms for almost 5 minutes, just giving us time to get more worked up (of course, some people would see this as time to 'collect their thoughts,' I suppose--cognitive restructuring, man, make it something positive!), and suddenly as I went in I could feel my face go numb and everything sounded echo-y and yes, I did a focused history and exam, and I didn't drop the stethoscope or lunge at the patient to feel her posterior lymph nodes (nothing like putting your hands around someone's neck without giving them warning), and I did wash my hands before and after thankyouverymuch, since failing to practice good hand hygiene is one of the few ways you can actually fail an encounter. I can't say too much more, since not everyone in my class has had their standardized patient experience yet (and there's an honor code saying you won't pass on information, that the exam suite is a secure testing environment, lah ti dah), but my patient did tell me that I "didn't do terribly at all," which hardly sounds like a ringing endorsement--but wait.
"You were just so nervous. I could feel your hands shaking as you were taking my pulse." Oy veh. But she went on: "You really have the personality for this. I can tell you'll be great at this, you just need to get over your nerves and then you'll be fine." Which I know is true; when I worked with Dr. B. doing preliminary interviews of his patients, they always told him 'what a nice girl' I was. Never mind that a 20 year old isn't really a girl, or that they were mostly geriatric patients who really needed someone to talk to, even if it was an inexperienced college student taking down their past medical history and medication information (but who was also willing to listen to them talk about their fears, and their grandchildren, and their gardens). Their bar for 'such a nice girl' wasn't very high, is what I guess I'm saying--just someone to smile, and listen, and care a little. Everyone needs to feel heard. Maybe that's what I need to focus on...maybe if I focus on that connection, everything else will fall more easily into place.

First anatomy exam

The first anatomy exam was, in fact, less of a debacle than I expected it to be. Of course there was test-anxiety galore (for everyone--enough to take me out of my shell and spontaneously fear/anticipation-hug two people in the hallway outside the dissection suite), and the test itself, well, it was engineered for maximum fun--if you were a professor watching, I guess. It's what I'd imagine a social psychologist would arrange to look at the effect of stress on anal-retentive, type-A individuals.

Put 30 of them in a room at once, where they can see each other scrambling and scribbling (or, if they get to a question they do know, standing idly and making everyone nervous because obviously that kid knows everything and I don't know anything and he's going to end up head of neurology at Brigham and Women's and I'm going to have to go live in a box).

Have at least 5 parts to every question. Incorporate as many different colored strings as you can into the question--the same goes for colored pins. If you have large and small pins in the same color, use both of them (I spent 30 seconds on one of the questions yelling in my head, "There is no mother #$*^ing large white pin!")

If you pin an organ that's easy to identify, make sure that identification of said organ is not a question for which students may receive points--rather, ask about vascular structures associated with it, or disease states, or its embryonic origin (that'll show the little bastards to skip embryology lectures).

Allow only 2 minutes per question. Use a buzzer to indicate the 2-minute intervals. Make it loud, so as to destroy concentration and work anxiety up to a fever pitch. If you have a student with long Q-T syndrome, see if you can put him into fibrillation with the combination of stress and buzzer. While not quite as dramatic, you may also be able to get someone to hyperventilate or faint.

Actually, while I'm speaking tongue in cheek, the anatomy exam was tough but fair. Nothing especially esoteric or ambiguous was pinned; there weren't any questions that were nebulous. There was even a 'rest stop' during one of the 2-minute periods with a bowl of small candy bars (proof that I'm "in the army now"--I took one of the candy bars and ate it. Outside lab, of course, but still...as one of the other students said, "Dude, that's dissection suite candy." I just think it was very nice of the TAs/profs to bring it in). And I passed, well above the requisite cutoff, thankyouverymuch, and when I picked up my paper (It may have been a little obnoxious, but I don't apologize) I did a little jig in the hall.

And now it's time to start studying for midterms, week after next. Oh joy. But seriously, there's nowhere I would rather be than here.

Fistulas and atresias and surgery, oh my!

So I'm learning about all kinds of cool (but sad) defects that can occur when there are failures in embryonic development--things that don't close that are supposed to close, things that close when they aren't supposed to, or close in the wrong place...

Considering all the things that can go wrong, as I've said before, it's a miracle any of us make it. There are duodenal atresias, where the intestines just stop (ending in a pouch) after the stomach...obviously, that's life-threatening; there are fistulas (ie, communicating tracts that shouldn't be there) between trachea and esophagus sometimes, which means you can get air in your gut where it shouldn't be (not that big of a problem) or food in your lungs where it shouldn't be (obviously a much bigger problem).

Then there are all the fistulas and atresias (atresia=something isn't there, or is blocked off) associated with the, ahem, genital and rectal region. I'll just say that the picture of a recto-vaginal fistula that I saw in lecture today is something that will probably be with me for a long time, haunting my dark moments. There's also something called imperforate anus, which is exactly what it sounds like: no anus. Just born without one. The large intestine doesn't go all the way down. I don't know why, but those were particularly 'what the hell?' pictures for me too--I mean, you hear all the time of people having heart defects, or spina bifida, or whatever, but no anus? I mean, c'mon, Mother Nature, quit having those three-martini lunches and get with the program here. There's a fairly standard design for a human body. Let's stick to it and not be adding or subtracting ESSENTIAL parts, shall we?

There's also something called gastroschisis (which I probably misspelled--Google it and check on me, since my brain is so full of anatomy right now that I don't have room for petty things like spelling or grammar) where a baby is born with intestines outside the body wall. Just hanging out there, chillin, as if they were on the front stoop with forties and cigs. And what's the solution, you ask? It's so simple I didn't believe it at first, but the pediatric surgeon said: "You just keep them in the hospital a few days, keep the intestines enclosed in a plastic bag so they're moist and protected from bacteria, and then roll the bag down like a tube of toothpaste." Like a tube of toothpaste, I swear to Goddess that's what he said. And gradually the body wall expands to encompass the intestines, and they all fit in there eventually, and the kid gets sewn up and gets a surgically-made belly button and everyone's happy. It really is amazing that after a period of a few weeks what were these tremendous, striking abnormalities could be almost completely resolved...that's the appeal of surgery, I guess: quick fixes. You do something, and you immediately see results. The inflamed appendix is gone and the patient recovers. The intestines go into the body wall, the blocked artery gets bypassed, the compound fracture is reduced and set. Psychiatry is on the complete opposite end of the spectrum, but somehow I think it's edifying in a different way. After seeing those pre-and post-surgery pics, though, I guess I understand a bit more why surgeons rag on psychiatrists. Of course, then the psychiatrists get to retort with hypotheses about God complexes and sublimated hostility and aggression. So everyone has fun.

Ativan, much?

So last weekend was our first official quiz in Molecular Foundations of Medicine (ie biochem).
The first time I went to take it (I was really hoping to only take it once, but we're allowed to retake them once if necessary, which turned out to be a very good thing) I totally psyched myself out. I was concerned with making it the best possible time to take it--that I'd gone for a run and had the post-workout sense of well-being, that I'd had a protein/carb snack to get those neurotransmitters in top shape (speaking of which, I really need to start taking my fish oil again--those omega 3s and 6s really are good for brain function, as I'll prove to you by posting a link to an actual scientific article when I can be assed to do it), that I'd had the optimal nicotine to caffeine ratio--not so much as to be jittery, but enough that the neurostimulant effects were out in full force. There was an article in the NY Times recently that said caffeine has both mood elevating and cognitive enhancing effects--to which any college student or working person will respond with an exasperated "duh."
So I put on my white noise machine to block out the workaday sounds of my apartment complex (and my roommate, who had family visiting) and sit down to take the quiz online. Yes, it's online. Closed-book, do-it-alone, online. I don't know how many of my classmates actually did it that way; I don't know if the professor is really that inherently trustful of human nature (though one would imagine that with 40 plus years of experience on planet Earth she must have considered the remote possibility that driven, type-A people, which medical students are almost by definition, might...bend the rules) but I did the quiz myself, just me and my computer, and lo and behold--I bombed. I literally felt like I'd been gutshot. I went downstairs to get myself the beer I'd been planning to have (either in a congratulatory or consolatory capacity) and damned if my roommate didn't ask me, "Are you ok? You don't look so good." I looked over my answers--the program lets you review them after you've taken the exam--and I had clicked the wrong boxes, I had missed words in the questions...a fustercluck. I'd just been so freaked out; about halfway through, I started thinking, "This is the first thing that really counts. This will be recorded for a grade, for posterity. This determines whether or not you will be able to pursue your chosen career." And of course I froze, and screwed up. At the same time, the sane and rational part of me (it exists, despite the numerous neuroses I vent here and the voluminous evidence to the contrary) was yelling at this critical, needling voice: "Shut up shut up shut up for Chrissake shut UP!" Did I say sane and rational? Sorry.
So I spent part of Saturday considering whether I should call the dean Monday and go in to say, "I'm sorry, I'm too stupid to be here. Obviously there was some sort of mistake. I should probably go." But instead, I studied up a bit more, did some yoga and meditation before I took the quiz again, and lo: my grade went up 20 points. Which goes to show: there is not a single human situation that cannot be helped dramatically by chilling the eff out. In fact, I repeat it to myself, mantra-like, sometimes: Freak not. I've always imagined that if angels came to people nowadays, like they did back when Jesus was roaming around, they'd have updated their language--and instead of saying "Fear not," like they told the shepherds at the first Christmas, they'd say, "Freak not."
So the anatomy exam is in less than 2 weeks. It's on the 29th, a day that for various reasons is one of the crappiest days I can imagine to have to really crank out a good performance. I spent several hours today going over the material (ie, two days' worth of lecture notes...which means I only have another 5,000 hours of material to get through). For me, the real sticklers are the heart and the autonomic nervous system. First, just the idea of the autonomic nervous system: that my brain is getting up to things without me being aware of it (though I guess it's good I don't have to think about breathing or having my heart beat--hey, cerebellum and brainstem, I'm not being ungrateful, I'm just saying...). And the heart, well, there's just a lot going on, especiallywhen you throw embryology and congenital defects into the mix. But I'm sticking with my mantra. And taking Ativan occasionally.

A warning

Do not fix yourself spaghetti primavera on a night you've planned to study the abdomen for your anatomy class.

Especially do not do so if you are planning to read and eat at the same time.

You will soon find yourself unable to do either. And after that, every time you see a mushroom, you will think of the spleen.

That is all.

Syncope is funny. Until it happens to you.

So I fell out during anatomy lab on Monday. I wasn't anywhere near the cadaver--we hadn't even uncovered him yet--and I was just listening to the professor talk about the sympathetic nervous system. It was interesting, enthralling even, so it wasn't like I was short on sleep and fell into a mini-snooze (I was short on sleep, true, but also highly caffeinated...to the point of buzzing, in fact).
I remember what he was talking about--the sensory innervation of the diaphragm, and the tests they do for fallopian tube patency (they inject some air into the uterus, the woman stands up, the air leaks out the openings of the fallopian tubes and impinges on the diaphragm, and the woman sometimes feels a little pain in the region of her shoulders or neck...because the fibers that innervate the diaphragm actually arise at the cervical--read: neck, not the 'downtown' cervix--level. Which is actually good, because it means that at least the fallopian tubes aren't scarred shut, which is a fairly common cause of infertility). I had to sit down. Stood up again, sat down again. Went out into the hall, sweating and nauseous, and prostrated myself (note my cunning use of vocabulary to avoid the lay/lie difficulty--something I still don't have a complete handle on after all my years as what I would consider an English speaker of some facility) on what is probably one of the nastiest floors--make that nastiest surfaces, period--I've ever been privileged to make contact with. So of course one of the professors/lecturers/coursemasters/whatever the hell we're supposed to call them now happened upon me, which was probably good considering the fact that I was horizontal and still felt like I was losing consciousness. Why me, dammit? I'm not especially squeamish (though the bone saw did make me flinch). I'm not some consumptive Victorian who keels over at the first sign of stress or pressure. So what gives?
Anyway, it was an embarrassing albeit unique opportunity to be escorted to and chill on the floor of the prof's office for a few minutes, eat a granola bar, and get my blood sugar up into range (I've decided it was probably an, ahem, glycemic control problem, which is a way of conveying the issue without getting all up in my business). This was the coursemaster who scared the hell out of me at the beginning of the year; I still have a healthy respect-to-fear ratio, since she comes around the lab and fires questions like bullets ("And what's this structure here, just posterior and medial to the thoracic duct?" [Silence, as the table collectively tries to remember what medial means in this context]), but she's also phenomenal at explaining things and was quite nice when she could have just shipped me to student health or something. So there's that. And the fact that I almost wanted to say, when she asked me what was wrong, "I'm either having an exaggerated vagal nerve response to stress, a particularly intractable bout of orthostatic hypotension, or a brief period of hypoglycemia that will probably rectify itself once the epinephrine from talking to you mobilizes the glycogen stores in my liver." Maybe I'm learning some of this stuff after all.

The heart of the matter

So we finally got to look at the heart. You'd think it'd be a fragile thing, especially after eighty-odd years of pumping, but at least in our cadaver it wasn't. I almost said 'specimen,' something some of our professors do from time to time...I'd like to avoid thinking of human bodies as specimens; for that matter, I like to think of even plant and animal exemplars as more than 'specimens'...to quote Mary Oliver,

"Is the soul solid, like iron?
Or is it tender and breakable, like
the wings of a moth in the beak of an owl?
Who has it, and who doesn't?
I keep looking around me.
The face of a moose is sad as the face of Jesus.
A swan opens her white wings slowly...
One question leads to another.
Does it have a shape? Like an iceberg?
Like the eye of a hummingbird?
Does it have one lung, like the snake and the scallop?
Why should I have it, and not the anteater
who loves her children?
Why should I have it, and not the camel?
Come to think of it, what about the maple trees?
What about the blue iris?
What about all the little stones, sitting alone in the moonlight?
What about the roses, and lemons, and their shining leaves?
What about the grass?
--Mary Oliver

His heart was thickened, as you'd expect perhaps in someone with heart disease; his left ventricle had been pumping against high blood pressure so long it was enlarged. When we cut the ventricles open, you could scarcely imagine they ever HELD any blood, the muscle was so hypertrophied. It was as if the thing itself had become so great, its function had all but been forgotten...how often does that happen?, I thought to myself. A cathedral becomes so glorious, overwrought with spandrels and flying buttresses and teeming masses of gilded figures, that the still, small voice it was meant to glorify is lost in the noise (of course, there are places--like St. Patrick's Cathedral in New York, or the Cathedral of Peter and Paul in Philadelphia--that are gilded and Romanesque but which do feel prayed in and USED rather than just admired...where the architecture feels like a solidified prayer rather than a distraction). A habit begins, to comfort and console, or perhaps to celebrate--champagne here, a cigarette to accompany a drink, five pounds lost to overcome a college freshman's feelings of ugly-duckling unbelonging. But it blossoms, and grows, and becomes more than it was ever meant to be, an ugly compulsion with a life of its own, the consoling or celebration or comfort lost in the cacophony of drive: alcoholism, addiction, anorexia.

So I have seen the inside of someone's heart now, the fantastic architecture, the membrane-thin walls of the atria and the thickened, hardy ventricles. I've seen the muscles that hold the valves in place, have run my fingers over the valves that even now are billowing diaphanously together in my chest maybe sixty times a minute (I'm always teetering on the edge of bradycardia--it's all the running). The valves are more like parachutes than valves as we think of them--phenomenally unmechanical, not at all stiff or thick (when they are stiff or thick, in fact, it causes problems and as such is labeled either insufficiency--if the edges of the 'leaflets' don't come together--or stenosis, if the valves are hardened and calcified). We're literally a few layers of cells away from dying at all times--it's amazing the ballet of our bodies doesn't get botched more often, that anyone manages to survive for any time at all.

What the hell is hemoglobin, you ask?

This is heme. It's part of hemoglobin (well, actually just attached to hemoglobin, which from now on will be abbreviated Hgb, by the way), the protein that carries oxygen and carbon dioxide in your blood and ushers it where it needs to go. Gorgeous, no? The whole Hgb protein is even more impressive; this is just the metalloprotein accessory group that makes the whole shebang possible. See, Fe (iron) likes to bind oxygen, but oxygen likes to (duh) oxidize things, including iron. So what's an aerobically respiring organism to do? Bind the whole thing up in a protein environment (ie, the interior of an Hgb protein--not a molecule, by the way, because it's made up of four individual parts. It's called a tetramer, from tetra for four--again the geniuses with the dead languages thinking no one will know what they're up to) where oxygen is prevented from oxidizing anything. Seriously, google hemoglobin. I urge you. Even if only to look at the pretty pictures. Just think--right now YOU are producing that. You, sitting there in front of the computer with your bag of potato chips (and, somewhat ironically, a diet Coke) are spinning out these amazingly complicated, intricately turned proteins. Damn. More on the coolness of Hgb to come.

The Thorax

It sounds like a Dr. Seuss story, doesn't it? Anyone remember the Lorax? Anyone?
But it's not...no Sneeches, no clear-cutting, no Grinch. Just the human trunk--the thorax, which is what we're currently looking at in anatomy.

On Friday we opened up the rib cage to get at the stuff inside. It was simultaneously fascinating and off-putting in that 1) It's not every day you get to look at real, honest-to-Buddha lungs and hearts, but 2) It's also not every day that you go at a human body with a SAW. And bonecutters, which are essentially larger and more specialized versions of wire-cutters. And in a way, it did feel like to sort of breaking and entering people generally get up to with wire-cutters (I can't say I've ever heard of anyone using wire-cutters for anything respectable, thought I'm sure it must happen--It can't all be stealing bikes and getting into chain-link fences). Instead of entering someone's compound, however, we were entering someone's chest. I was elected by our group to do the first few cuts of the ribs (again with the if-you're-squeamish-skip-down-a-bit warning) and I have to say, it was hard work, and made a sound that could be described as either disgusting or highly satisfying, depending on your bent. The clavicles and xiphoid process (the end of your sternum) we went after with a saw, since apparently they're too tough for even bonecutters to work (yes, it was essentially a saw just like the kind you'd use on wood, with the exception that it was bright yellow and due to someone previously doing a less-than-stellar cleaning job had bits of...something organic on it). I'll admit it made me a little woozy, and I handed over the cutters as soon as I'd done my requisite couple of ribs.

I didn't actually see the heart; it's covered by pericardium, really very well veiled by filmy white tissue, which seems appropriate--who wouldn't guard their heart a bit? Don't we all do that, not just anatomically but metaphorically and emotionally? The lungs were on full display, however, with their covering of slippery, whisper-thin pleura, and as springy and pink as the various preservative solutions would allow (soft tissues have a tendency to harden in the presence of preservatives, which is advantageous in many ways but not so great in others). One of the neighboring tables' cadavers was a long-time smoker...needless to say, there were dark spots all over and the lungs weren't nearly as pink and spongy as ours. Perhaps medical school will finally cure me of my smoking addiction once and for all--nothing like looking at the actual, physical results of your particular vice to get you to "straighten up and fly right," as my father would say.

overwhelmed? who, me?

Not by courseload, necessarily, but by sheer volume of information. Each class is actually multiple classes, with multiple sections: one course is comprised of physiology and histology together (and histology is both a lab and a lecture course); anatomy is a lab, and a lecture, and has some radiology thrown in for good measure, and the 'doctoring' course has a seemingly infinite number of sections, subsections and small groups. In a few weeks I'm sure I'll be fine; for now, I'm basically just buzzing with a combination of excitement and anxiety.

Not to mention the information our instructors are actually trying to convey to us INSIDE lectures and labs--and the fact that while some of it is hard and fast (insert your double entendre here) a lot of it is open to interpretation--for instance, when one of our anatomy instructors looked over our cadaver today and told us,

"I'm going to say that's the deltoid branch, but someone else might tell you it's the clavicular, and really it could be either." (Yes, I cut an artery by mistake and then we couldn't tell where it was supposed to be branching. "You're going to cut important things," she added. "It happens. Some people get really bent out of shape, but if you just expect it to happen, it's not that big a deal." What? Someone not advocating rabid perfectionism? Hot damn, I did come to the right school!) Same in histo. "Is that a macrophage?"
TA: "It could be. It could also be a plasma cell; it's not a textbook example of either one, though."
What I DON'T say: "So how helpful is the textbook then? And how can anyone ever be sure--like pathologists? Let's talk about the epistemology of the macrophage and the illusory nature of nomenclature and classification."
What I do say: "Also, could you tell us what this structure is? It's not in the lab manual."
TA: "I have no idea."

I kid, I kid. The TAs are great, the instructors are awesome, and I couldn't be happier to be here. It's just that enzyme kinetics AND all the structures of the thorax AND the classification of cartilage, bone and epithelium AND biostatistics (even though it's not called that) AND how to take a history and physical...all at once...is a lot. Check in with me again a week before midterms and no doubt I will laugh at the naive and spoiled me of August who wrote this entry; but here it is.

Cadavers, Humanity and Faith

So our first day in the anatomy lab was today.
Today I made my first incision into another human body.
It was at once sobering and exciting, this rite of passage, a threshold every future physician has to cross and probably remembers for the rest of her life. It was also just incredibly, utterly cool.

The face, hands and feet--probably the most human parts of any body--were covered with stockings, both to make it easier for us to do what we had to do and to protect them from desiccation.
The body itself was that of an eighty-ish man, who died of complications of heart disease; he was a middling-sized man, not the wasted habitus you sometimes see in old age or advanced infirmity, but not huge. I thank him for his gift to my learning.

We began by cutting flaps of skin on the chest and reflecting them back, then working away the fat until we could see the superficial fascia (tough coverings) on the pectoralis major, serratus muscles, and deltoids. There was a fair amount of fat to cut away from the ribs; we worked a little too far inferiorly and ended up exposing a little bit of the rectus abdominus as well (the abs, for those of you with any passing familiarity with SHAPE magazine et al). I never realized how much fat there is in the average body--not just in a large person, but in a person period. It made me feel a little better about my latest body composition stats. The people with female cadavers sectioned the breasts to get a look at the lobules and such that comprise the milk producing tissue--no one found much, considering that most of the donors were fairly advanced in age and the lactation apparatus etc. sort of atrophies (ie shrivels up) with age--nature is quite parsimonious, and what you don't need you generally don't keep. One group did have a female cadaver with breast implants--I lacked the wherewithal to actually handle one, first because I think breast implants are gross in general, second because (spoiler alert, if you're squeamish skip to the next paragraph) they were covered with grease from the aforementioned abundant fat.

It's difficult to walk the line between remembering that these were once human beings aand as such are inherently due respect and compassion (and depending on your religious and moral bent, still are people--I got called out on this at the Christian Medical Association meeting, where one of the participants 'reminded' me that "They aren't people anymore--the soul has departed, they're corpses." I'll write more on the CMA later--it's not the best fit I could have hoped for, as it seems populated primarily by mainline and right-leaning Protestants that would probably have heart attacks if they knew the extent of my interfaith Episcopal/Quaker/Wiccan/Buddhist hippy-dippiness. However, they're nice folks, and when I go to their meetings they feed me, and the lingo--"glorify the Lord," "the things of the world," "being a witness for Christ"--reminds me of the church I went to in elementary/ middle school, which is simultaneously comforting and kind of painful) and jsut focusing on the anatomy, doing what you need to do, and forgetting for a little while that you're working on a person. Selective attention, I guess you could call it, or selective numbing. You can only focus on so much, and while of course I never want to treat anyone or any body (pun intended) I meet as just a hunk of flesh, for the purposes of this course I think I'm going to have to depersonalize the cadaver, at least a little, at least for a while.

Anatomy, Day 1

So today's the first day of anatomy, and I have 3 primary goals for today (I always knew those goal-setting seminars I went to in high school would have a purpose beyond giving the counselors work to do and me a way to get out of class):

1. Don't hyperventilate, pass out or throw up in the anatomy lab. I'm usually not that squeamish--I watch the surgeries on Discovery Health on occasion (at least at my parents' house, the only place I've lived in the last year that had cable), but there's a big difference between sitting on the couch with a bag of pretzels and actually being gloved up standing next to a no-longer-living person. More on this later, no doubt, after I've actually done my first day.

2. Don't cut myself, or anyone else, with the scalpels. I'm talking accidentally, of course--It's not like I'm going to have to be restraining myself from spontaneously dissecting my tablemates (although I've heard that, as a profession, medicine harbors one of the largest percentages of serial killers. Creepy, huh? I guess it's the combination of God Complex, poor pedagogy that presents the body as a piece of meat rather than a human being, and the sort of cunning--and I use that in the nicest way, just to mean 'smarts'--that drives people into this particular calling).

3. Manage to get changed and spritzed with perfume (to cover up the eau de formaldehyde I'll doubtlessly be exuding) in time to meet my clinical preceptor on the inpatient unit this afternoon. From anatomy scrubs to clinic-ready wear (which kind of feels like drag, to be frank...but more about that too, no doubt, as time goes by) in forty-five minutes, with time for a lunch talk from the AMA in between? I think I can. I know I can. I am the little train that could.

Medicine and the humanities meet...and the result is poetry

This morning

Walking down Euclid, that name
which puts me forever in mind of angles and arcs,
I saw a young boy walking with his mother,
'Spastic,' the official term,
so monstrously unfitting:
His arms were kept
clenched closely to his body,
As if he were cradling himself;
His face was like an empty plate,
that youthful newness
still aching to be piled with good things--
Skin china-fine, and equally as pale,
through which I could see his bones
and the meandering tributaries
of his veins.
His geometry was warped,
angles acute,
The delicate spine's arc
twisting to the right--
and yet he walked on two
straight, honest legs
past me and on
into the morning light.
-AG

I sing the joys of biochemistry

Today was our first official biochemistry lecture--or, as it's called here to make it sound clinically relevant and less like a rehash of that class you took during your killer 21-credit-trying-to-get-into-med-school-junior-second-semester, "Molecular Foundations of Medicine."

There was the "two semesters of gen chem and organic chemistry and biochem--each" crammed into an hour, and then we talked about prions and prion-related diseases, which are actually pretty cool. People thought Stanley Prusiner was a total whack job when he first said, "Hey, these aren't viruses and they aren't bacteria--maybe they're just misfolded, infectious proteins." I would imagine they told him, "Stan, you're a misfolded protein." But now that guy down the hall who made fun of him when his paper was rejected hangs his head in shame every time he's reminded of those comments, and Stanley has a Nobel Prize, so ha freaking ha. Chase your dreams, kids. Don't be disillusioned.

We also had a Practice of Medicine, or "Doctoring" class, and got to watch a sample interview/physical, where we learned such gems as (I'm actually not being ironic--moi?--some of these were things I'd never even thought about, or had thought about but will likely forget when I go in for my first interview smelling of sweat and hand sanitizer and fear):

-Introduce yourself, and sit down. Studies have shown, one of the clinicians noted, that when you sit down with patients they feel like you've spent more time with them, and hence they are more satisfied with the whole experience. Also, you're not towering over them (not that my 5'4" self would be doing much towering) and even further emphasizing the power imbalance inherent in the relationship.
-Tell the patient what you're doing before you do it and as you do it. Don't lunge at people without explaining what's going on. With adults, you'll make people uncomfortable; with pediatric patients, you might get bitten.
-Listen. What a concept. Don't barrage the patient with questions. Segue to the topics you want to cover in a SMOOVE manner. If you're good at macking on people, apparently, you will likewise be good at getting histories. Please don't mix the two and mack on patients, by the way, especially if you're an OB/GYN. Because it's not just creepy, it's an ethics violation.
-Wash your hands.
-Warm your stethoscope and hands. And if you're using one, the speculum (since I'm 99.9% sure I won't be going into OB/BYN, I'll say this simply as a woman...there is nothing like a cold speculum. And not in a good way).
-Ask follow-up questions. Ask people to clarify. "I used to party..." could mean anything from getting funky with birthday cake and those paper cone hats to snorting crystal and having sex with other men. Obviously one is a risk factor for a lot of things, and the other isn't so much (OK, maybe diabetes if you eat a LOT of cake).
-Related vein: don't assume risk factors--or anything, really--based on appearances alone.
-Wash your hands.
-Be friendly. Smile. Say please a lot. This person is giving you access to their life history, their secrets, their body. Be compassionate and polite.
-Wash your hands.

Oh, yes, in histology yesterday we had our first "Joke at the Psychiatrists' expense."
"As for the people who never learn to identify anything under the microscope, we just hope they go into psychiatry or something." I wanted to say, "Really? This early you're hating on the psych folks? REALLY?" I guess everyone just pimps everyone else and I should get used to it, but come on now. It's a little early to be establishing pecking order, isn't it (I say "establishing" as if psych weren't sort of entrenched towards the bottom...but at least people TALK to them. Pay quite a bit to talk to them, in fact. Let's see any other kind of physician, even a sparkling conversationalist, who gets paid just for their words).

And So It Begins.

I've just finished orientation at a certain well-known and fairly prestigious medical school in St. Louis. The white coat ceremony was today, and I have to say I enjoyed it; we read the oath we (as a class) crafted, stating our intent not to shaft our patients, our faculty, or each other, listened to several speakers tell us 1) how awesome we are 2)how awesome Wash-U (damn, I let that slip) is, and 3) that there are wonderful benefits--and grave responsibilities--that come with being a physician.

Somehow I am anticipating that the "y'all are fantastic!" may not carry very much farther into the semester, so I aimed to enjoy it while it was available. Then again, I have a tendency to anticipate the worst and expect people to turn on me without warning or provocation, so that could just be my own neurosis speaking.

The following are some quotes that sum up what this week was all about for me.

"Hi, I'm X. What's your name? Where are you from? Where'd you do undergrad?"-everyone
So I learned that people here are friendly, outgoing, and in some cases (although I think I only met one...) eager to let someone know they went to Harvard.

"If you fail an exam, I'll know, and we'll have a warm and fuzzy chat about how you're doing."
-One of the deans
So it seems people here aren't primarily interested in nailing you to the wall, but rather in ensuring you do well and checking in with you if you're not. I pray to Christ, and Isis, and Buddha, that I don't ever have to have a "So you're screwing up academically" warm-and-fuzzy-conference; however, the overall feeling of someone watching out for you--not in a creepy, Dick-Cheney-who-would-put-cameras-in-every-American's-bathroom-if-he-could way, but in a caring sort of way--is reassuring.

"Additionally, if you have to be taken by ambulance to the ER for alcohol poisoning, I will know that too. And we will have a different sort of chat." -the same dean
Well, I'm on my ass after one drink. The probability that I would drink myself into ethanol toxicity is approximately as remote as the likelihood that all my electrons would suddenly shift phase and transport me to Aruba, a la the Philadelphia project (seriously, the whole Philadelphia project was really cool. Google it, please). Also, Dean X's knowledge and sight is truly without limit, and her reach knows no bounds. Who knows what evil lurks in the hearts of medical students? Dean X knows, and she will totally file a professionalism concern form on your ass.

"I woke up on X's couch this morning and didn't know where I was. It took me a full five minutes to figure out what the hell happened last night." -a fellow first-year
So apparently there are others with greater capacity for drink than I, and additionally our class has already begun to bond to the point that we're crashing drunkenly on one another's couches. That's the sort of camaraderie that I think orientation week is meant to foster, no?