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.