Finals Week Poetry Breakdown

Reflecting on this block's learning experiences, with a poetic form suited for each.

Pathology (the haiku, a form of infinite subtlety, that nonetheless comes down to just a handful of words--much like a path report).

Bridging necrosis
and Mallory's hyaline:
cirrhosis, but why?

Kill the eponyms?
But won't we hurt Cushing
and Virchow's feelings?

If I never see
One more liver biopsy
It won't make me sad.

Bullous pemphigoid
or mycosis fungoides?
Which one looks grosser?


Dermatology (couplets--short and sweet, and simple to write, just like prescriptions for Retin-A and steroid cream).

Your autoantibodies to desmoglein three
mean pemphigus vulgaris. Better you than me.

I'm sorry to inform you, your mole's cellular division
has crossed the line, and now it's time for a complete excision.

The necklace hubby bought you has given you a rash;
it's called contact dermatitis; next time, tell him, blow more cash.

(Especially for Dr. A. C. L. of dermatopath):
If the lesion is pigmented but the biopsy's a shave
expect at best an angry phone call and at worst an early grave.


Endocrine (Limericks--because everyone knows endocrinology is funny. Right? Um.)

A woman who hailed from Tacoma
had a sizable prolactinoma.
She started lactating,
but more devastating,
Her leg hair required a comb-a.

The doctor she saw told her, "Well,
I can see something wrong in your sell'
turcica--if you're keen,
Try this cabergoline,"
And she did, and it all turned out swell.

GI still to come...

African albinos

Part of a physician's duty, one could argue, is to help protect the vulnerable--whether that means reporting child or elder abuse, ensuring informed consent, or preventing the possible leak of someone's HIV/AIDS status. Currently, health care workers (among other social service personnel) are busy in Tanzania, trying to provide safety and care for albino individuals. See here and here.

There are two main threats to albinos in East Africa: one is skin cancer (what happens when you take a phenotype already prone to cutaneous malignancy and add tropical doses of UV light); the other is 'poaching,' a term usually reserved for animals, but which seems to capture the brutality of the attacks on these people. Local...um...I don't think there's really a PC word for witch-doctor...local animist and Voudoun practitioners claim albino body parts are powerful charms for luck and riches; others use albino blood in their spells. The world is a wide and strange place. But lest we assume that these people are (to quote a commenter on one of the sites) "superstitious, bestial savages," let's remember that--killing aside--a lot of people in the US still wouldn't want to shake hands with an HIV positive person, or someone with psoriasis. Suprisingly, albinism is exponentially more common in Tanzania than in the US.

What got me started on this train of thought? Why, studying vitiligo for my dermatology exam, of course.

Basically, Everyone's Crazy

It's like that song from Avenue Q, "Everyone's a Little Bit Racist."
Today we talked about 'functional somatic syndromes' in our doctorin' class. These are syndromes, ahem, "defined more by suffering and symptomology than by any consistently demonstrable pathophysiology." Which sounds a lot like saying "it's all in your head." Which, to me at least, sounds kind of paternalistic and dismissive--medicine as an entity and doctors in particular putting the burden of 'un-understandability' on the patient rather than admitting that Western medicine doesn't totally have its shit together with the whole mind-body connection. A little like hubris, I feel. In one of the articles we read for today, the authors listed 'side effects from silicone breast implants, irritable bowel syndrome, repetitive stress injury and vaginismus' as among these functional somatic syndromes. The paper was written ten years ago. In 2009, we have official diagnostic criteria for IBS and fibro; everyone and their sister knows that carpal tunnel DOES, in fact, exist; and I'm gonna go out on a limb here, but I doubt that even in 1999 a reasonably intelligent person would say, "Have 500 ccs of potentially allergenic, if not carcinogenic, material pumped into each of my breasts? Don't mind if I do!" As for vaginismus being an issue of mind over body--yeah, possibly, but that doesn't mean the suffering isn't real, and telling women to just relax about it doesn't address the problem. I guess what I'm saying is, we don't know everything there is to know about the world, and it's kind of pompous to say that if we don't, it's the world's fault. After all, just 50 years ago doctors were still telling women that dysmenorrhea was all in their collective heads (and had, apparently, been a form of mass female hysteria since time immemorial).

Our group leader described his thought processes well--when prescribing a tricyclic antidepressant for a woman with irritable bowel, it's common to be met with the dismayed cry, "Doctor, you think I'm crazy! I'm not crazy!" At which point he then points out, "Your gut is very special--it's the only organ system that has a complex 'brain' of its own...(explain about the enteric nervous system, neurotransmitters, la ti da ti da) and I think that these drugs, even though they were originally prescribed for depression, might have some usefulness here." Meanwhile, he says, 'I'm thinking, yeah, I do think you're a little bit crazy, but so's everyone.' So that's a nice message to keep in mind next time someone's acting like a whack job and being really frustrating--everyone has their own particular flavor of crazy. It's like the world is a huge Baskin-Robins, but with neurosis instead of ice cream.

Healthcare professionals make the worst patients

So after the heady delight of yesterday's clear liquid diet and colonoscopy prep (read the details here, if you're inclined--it included 1) a grand total of 17 trips to the bathroom, 2) the drinking of 2 liters of a substance whose foulness could probably be approximated by mixing together 2 liters unsweetened lemonade, a cup of salt, and a few tablespoons of rancid butter, 3) my internal organs producing rumblings and gurgles more commonly associated with active volcanoes and hot springs)--came the event itself. The things I remember, after the glorious sedative/miracle that is Versed:

1) The anesthesiologist was kind of a jerk. Not mean; just not real heavy on the people skills. Example: "Did you eat or drink anything today?" "Yes, some diet coke. A few ounces." "When?" "To take my Synthroid this morning..." (interruption) "I said when, not why." Maybe I'm hypersensitive, but slow your roll there, Dr. Feelgood. I flushed a little bit at this--because hey, I'm here in a 2-ply paper gown about to have someone spelunking in my colon; I'm worried about my own asshole, so I don't want to worry about what you've got wedged up yours right now. "You've got a sort of rash on your chest. Have you noticed that?" Poking my chest, checking to see if it blanches...poke, poke, poke. Hey, why not ask before you start prodding? Just a thought. And I'm flushed because I'm pissed off but I'm not good at verbalizing anger.

2) The nurses were awesome, as nurses usually are. Warm blankets, and this hose that essentially blew warm air through the blankets I had on to keep me toasty while I waited. Someday I'm going to make friends with a medical supply rep and get one of those for my house. Or, you know, an electric blanket. Probably cheaper.
There was one bit of an awkward moment--the nurse was explaining things to me in that reassuring way that nurses have, while I was looking at the pulse oximetry reading and trying to consciously lower my heart rate to sub-tachycardic levels (have I mentioned I'm kind of tightly wound? And that I've been obsessed with controlling my heart rate and blood pressure since I read an article on biofeedback in sixth grade?). "And you can just relax--we'll have machines to keep track of your heart and your breathing, and the doctor will give you some medicine to make you nice and sleepy...now what grade did you say you were in?" (I'd mentioned being a student.) "I'm a second year medical student."

3)Apparently the doctor came into the recovery room and explained everything, but damned if I remember anything. Thanks again, Versed!

Nazi doctors: read with caution

A lot of what I write is relatively...light in nature. I've been told I'm funny, at least (which is better than just being funny-looking--what I'd be left with otherwise). Recently, though, the question of just what the ethical standards of physicianship are has come up at WUSM. There was a presentation on the atrocities perpetrated by the Nazi 'doctors' (I put doctors in quotes because those who so demonstrate so clear and complete an absence of conscience, so utter a disregard for humanity and decency, no longer deserve the title), and--understandably--there has been some upset, mostly related to some not-so-sensitive questions that were asked afterwards. Namely, whether the Nazi doctors were subjected to peer pressure, and whether this in part explained their actions. I will add that I was not at this talk, and so am at best dealing with secondhand information about said upset...realistically more like third or fourth-hand, with the attendant reliability issues that entails. Nevertheless, this seemed like fertile ground for exploration, and something about which I must make my opinion known.

As most people (I hope?) know, the Nazis' crimes against humanity included 'medical experimentation' conducted chiefly by 'Drs.' Josef Mengele [Auschwitz, all manner of horrors], Carl Clauberg [Auschwitz, both forced sterilization and forced impregnation, ie rape], Sigmund Rascher [Dachau, especially high-altitude and hypothermia experiments], and--killing any naive belief one might have that women are always nurturing and incapable of such vile inhumanity--Herta Oberheuser [Ravensbrueck, creating 'battle wounds' and infecting them with gangrene and staph]. To call their undertakings 'research' is to defile both that word and the memories of those who were tortured. Mengele is perhaps the most infamous of these doctors; his experiments, particularly on twins, are the stuff of nightmares. He injected solvents into twins' eyes in attempts to alter their color, performed surgeries--like intestinal resections--without anesthesia, and allegedly attempted to 'create' conjoined twins by sewing a pair of Romani twins together. These are not the acts of a scientist, however depraved, and they are most certainly not the actions of a physician. They are what happens when an already sick individual is given such power that his perversion becomes florid, all-consuming, utter. They are what happens when a psychopath is not subject to the slightest judicial or societal restraint.

I've known about these things since middle school, when the Holocaust was first mentioned in our history classes and I found myself appalled that such things could have happened; not so much that Germans 'allowed' it to happen (there is something to be said for what someone does under duress, the ways in which a totalitarian state twists the mind and the soul--read Alice Miller for an in-depth exploration of this from a psychoanalytic perspective). Reading and hearing about them has an effect on everyone merely by virtue of their humanity: it is impossible not to be repulsed. As a medical student I find that my response, while essentially the same, is still more profound.

As a physician-in-training (not even yet a doctor) I took an oath on the day I got my white coat; more importantly, I made a promise to myself and to the world when I chose healing as a profession. I swore that above all, I would do no harm; that I would always put the needs of my patients foremost. I promised that I would act with humanity, compassion, and humility, and that I would work for the preservation of human life and dignity. There are circumstances in which this is not easy--when, indeed, it might even seem unfair. As a specialist in Jewish medical ethics said at a talk I once attended, if a terrorist and three of his victims come into your ER, and the terrorist is triaged at a higher level than the victims, he gets care first (ideally, of course, everyone's getting it at the same time). Or, to paraphrase a little-heard B-side of Alanis Morissette's, if a man's in the emergency room with a bleeding head because he was beating his kid and she hit him back...you still stitch up Dad's head. WITH adequate anesthetic (not, of course, that I would think of doing it any other way).
L'olam lo suv. Never again.

Day of Diarrhea

Laugh, if you must. After 6 hours of lecture and small groups devoted to the intricacies of the human bowels, I certainly did. Maybe I was a little slap-happy, getting back in the swing of things after an entire (gasp!) 48 hours sans studying--but by the last hour of lecture yesterday, I was seeing double-entendres everywhere.

"There are two etiologic categories for diarrhea. Number one isn't that important, but number two..." *Snicker*

"There is a wide range of frequencies for bowel movements." (Display of an actual GRAPH of the number of bowel movements per day--in case you were wondering, 'normal' runs from three times a day to three times a week, and the median is once a day.) "As you can see, the graph peaks at once a day, and sort of tapers at either end." *Hee hee*

"Diarrhea is frustrating to diagnose, but it usually comes out all right at the end." *Further laughter, and the recognition that I have the maturity of a fifth-grader.*

Awards

Today we had the 'Distinguished Service Teaching Awards' at school. Which mostly translated into 'free reception snackies and diet Coke...and alcohol, but no alcohol for you, because you're trying to cram another hundred renal facts into your cranial vault in the next twelve hours, and champagne will not help you do that.' So, in the spirit of such awards, let's hear it for The Body Systems, Organs, Diseases, and General Medical Stuff Awards! Yay! (Sponsored by Valtrex).

Most alarming symptom that's usually fine: Rectal bleeding. Notice I'm NOT a doctor, but rectal bleeding, especially when accompanied by pain, is usually hemorrhoids--and you'll usually be fine in a couple days if you get your hands (well, not your hands exactly...) on some hydrocortisone suppositories. Yes, suddenly being confronted with unexpected blood--particularly from this region--is distressing (as I *almost* said to my physician when she asked 'how much' bleeding I was having, "I don't think there's an acceptable lower limit for ass blood"), but it's nowhere near as bad as, say, vomiting blood.

Most innocuous condition that makes me wish I were dead: It's a tie between menstrual cramps and migraines, both of which feel like I have tiny angry elves inside my body trying to hack their way out with pickaxes. Sometimes I get both at once (oh joy! It's fairly common, apparently, and has to do with all those shifting lady hormones), and all I can do is stay perfectly still in my dark, dark, bedroom with earplugs in and a heating pad on. Oh, and take Ultram. I don't think it's a narcotic...

Grossest-looking infection that is in no way dangerous: Onychomycosis, or for those playing the home game, fungal infections of the nail bed. The thing is, it's not limited to people with poor hygeine, either...sometimes you'll be at the pool and some cute little twentysomething will walk by and only when you look down do you notice that she has, not to put too fine a point on it, toenails like corn chips. Fritos.

Prettiest-sounding infection that's actually quite gross: Chlamydia.

Most recent disease to be stripped of eponym status: Wegener's Granulomatosis, now ANCA+ vasculitis or granulomatosis (because it turns out Dr. Wegener was a Nazi, which is actually really not cool).

Laziest 'organ'- The appendix. Yeah, that's right, I put organ in scare quotes.

Overachieving organ: The liver. It does everything. If you've been reading this blog for any length of time you know my love of the liver is vast.

Organ so large and in charge you don't even think of it as an organ: The brain. More than a traditional dish in the zombie-American community; it's what keeps everything running smoothly.

Quotes from Urology Lectures

First, I wonder what urologists tell people they do at parties. It seems like one of those areas of employment where, despite the fact that it took over twenty years of schooling to attain, you might be tempted to...well, not embellish the truth. Not embroider it, certainly...but, perhaps, omit. "I'm a doctor," you'd say, or a surgeon. I'm in men's health, maybe. Because otherwise there will be jokes, almost certainly of questionable quality, and the teller will probably think he's the first one ever to think of something so hilarious, and you'll get thrown out of the party when you finally succumb to temptation and punch him in his damn mouth. That said, some quotes from our urology lectures.

"It's very important to find out what kind of sexual dysfunction a man's experiencing before you just send him home with Viagra. Because if the problem is anorgasmia, and he's been taking 30 minutes to get things done, and you give him a vasodilator-- well, not only will you not solve his problem, but when he's now going 60 or 70 minutes, his wife is going to come looking for you. Probably with a gun."

"The commonest problem in young men is actually not ED--it's...(pause for answers, all of which--interestingly enough--were provided by the women of the class) premature ejaculation, that's right. And you're going to have to ask about it, because I can guarantee you, no one ever comes into the office and says, 'Can you help me, doc? I'm a premature ejaculator.'"

"Men will tell you that they use recreational drugs to treat their ED. Listen, guys: Pot and coke don't make it easier to maintain an erection or anything like that. You just don't remember the erections you aren't having."

Things I learned this week, and some quotes

1. "In a differential diagnosis, include the 'mosts.' The most common, the most dangerous, and the most interesting. Though in the case of acute chest pain, skip the most interesting. Because if someone has ST elevation on their EKG and you're talking to the resident about parasitic pericarditis, they're going to hit you with the clipboard. And so they should."

2. "Speaking as an internist, every last one of you in this room has a pulmonary embolism until proven otherwise. That is something you never ever want to miss."

3. Apparently there is an outlet for my hypochondria and tendency to catastrophize: unleash it on my patients! "Put in the differential the absolute worst things it could be...the really bad shit. Because you'd feel really bad if the patient died and you had to say, 'Oh, a pneumothorax...I never thought of that!'"

4. 'If a little is good, a lot is better' does not apply to high-fiber cereal bars, no matter how tasty they may be. Remember that SNL spoof about 'Colon Blow' cereal? Back when SNL was funny? Yeah.

5. Physicians, especially ER docs, really seem to relish catching malingerers. Their eyes always light up when they talk about it, and they start grinning like feral chipmunks. For instance, someone complaining of chest pain angling for MI-type attention who says it hurts when you press *right there* is probably faking it. That's musculoskeletal. "I always tell them, oh, good, I think you're out of the woods. Peace."

6. Having whacked out hormone levels (though not, as of yet, any confirmed $%&# diagnosis) has made me a little...hairier than usual. Supposedly acne is also part of the sideshow. "At least I don't have that," I consoled myself. Wrong. Long workouts + androgens + ubiquitous bacteria = not just acne but, cruelly, ass-ne. *Is there no end to the ignominy?!?!*

7. My first hospital session (with an actual patient) is next week. I'm a little (ok, a lot) nervous. Hopefully I will not blind the patient with the ophthalmoscope or forget part of the physical or lose my train of thought during the history and just sit there staring blankly. No. All will be well.

Does she or doesn't she?

Only her reproductive endocrinologist knows for sure.

The 'so, do I have PCOS?' circus continues. Altered hormone levels, especially high androgens (male hormones)? Check. Irregular periods? Check. Increased (ahem) body hair? Yeah, fine, check. Obesity? Well...no, but the comorbid eating disorder could have something to do with that. So what's the most distressing? Honestly, the hair (this from someone who hasn't shaved since middle school). I feel like I'm either going through puberty again or turning into a wolf. Or possibly both. Wasn't there a book during the eighties called 'I was a teenage werewolf?' I think there was.

Americans have really...effed up responses to female body hair. When I wear shorts, I catch people staring. A lot. I wish, if they were really that curious, that they'd have the testicular fortitude (ie balls) to come up to me and say, "Hey, I think your particular style of bodily presentation is really different and kind of cool. Would you tell me a little bit about why you do things this way?" Then I might not want to disembowel them with a spoon for tee-heeing with their friends behind my back at the Metro stop. Y'know, the way I do now.

In a 1998 study, 125 undergrads of both sexes were shown 2 videos of a woman drying off after a swim. In one she was clean shaven, and in the other she had hairy armpits and legs. The unshaven woman was rated as less: moral (?!?), relaxed and fun; she was rated as more assertive, aggressive, serious and 'in better physical condition.' This was the same woman, mind you. The only difference was the presence vs. absence of hair.

A few days ago, on what I generally consider to be a feminist blog, one of the commenters (in discussing her feelings about fat acceptance vs. fatphobia) brought up the subject of choosing with whom one associates, and said, "For instance, I think women have the right not to shave if they don't want to, but I still think it's abnormal and weird and I probably wouldn't want to spend a lot of time with them." REALLY? AYFKM? (Think it out...Are You F*cking Kidding Me?) Just having looked at me, without so much as a hello, you know you don't want to chill with me based on the state of my hair follicles? Not to mention that it's NORMAL for women to have body hair--IT GROWS THERE AND WILL BE THERE UNLESS YOU ACTIVELY REMOVE IT--and so the whole "It's abnormal/weird" argument is proof positive that you've bought into the consumerist/patriarchal/western beauty complex.

The excess hair associated with PCOS is called 'hirsutism,' and it really isn't so much an excess of hair (though it can be) as it is a male-pattern hair growth--ie, on the chest, the lower stomach, the shoulders, upper lip and chin, lower back. Most people bleach it/electrolyze it/shave it. Some people, like Circus Amok performance artist Jennifer Miller (google it...you'll like it) don't. It's all part of the pulchritudinous plethora of personalities we call life. So for now, I'm going to discreetly pluck a few places...and leave the rest.

Fun quotes from the past week

Pulmonary lecturer: "If there's blood in the pleural space, obviously the lung can't expand there. Two bodies cannot occupy the same space at the same time...though, of course, it's fun to try."

Renal lecturer: "So if this woman has 6 liters of extra fluid on board but she doesn't have pitting edema, where did she put it?"
Student: "I don't know, in her hump?" (full disclosure, it was me.)
Professor: "What?"
Other student: "She's a camel!"

Other renal lecturer: "And if you had to guess which diuretic Peter Griffin from Family Guy is on, you would guess spironolactone. Because of the gynecomastia." (For those playing the home game, gynecomastia is when men develop hypertrophic breast tissue; in layman's terms, man-boobs).

Today's Lessons...

Not necessarily related to class--though some are.

1. No one ever has pheochromocytomas (tumors that produce excess adrenaline and noradrenaline), but lots of people have the symptoms. The symptoms are really common and vague--palpitations, flushing, jitteriness. As an intern, you will run lots of labs trying to track down a "pheo," imagining the 'House'-ready moment when you present your off-the-wall find to your attending and are crowned with laurels and fanned with palm leaves by the more junior medical students. One problem: you will not find them. They are the Easter Bunny, the end of the rainbow. Never there. Oh, and fun learning point: "Pheo" is a root meaning 'dusky.' Guess the tumors are dusky colored.

2. According to several people in my class, "Snickers are the healthiest candy bar. The most protein, the most fiber. No, seriously." I would say that if your eating habits have reached the point that you are SERIOUSLY considering the nutritional merits of Snickers bars, you have bigger problems than that extra 2 grams of fiber can address.

3. Not even the promise of cupcakes was sufficient to lure--I mean, encourage--more than 5 people to come to the Medical Students for Choice meeting. Why? Because another interest group was having a meeting and serving lunch. Since when does lunch beat cupcakes? Especially cupcakes with that layer of frosting that's so thick and firm you can pick it off the pastry and eat it by itself? Damn, now I'm all hungry.

4. In low-bloodflow situations, tissues (including the heart!) are capable of entering a 'hibernating' state where oxygen need is reduced and metabolism slows; upon reperfusion (ie the return of blood to the area) metabolism picks right up again, albeit with modifications--including modifications that are protective in the event of future ischemia! We are truly adaptable creatures.

5. I'm a soprano and all, but hitting a high A (as in, a ledger line above the staff) is...difficult.

6. When you're a medical student, you dissect the aorta and appreciate how thick it is, how muscular while still being elastic and distensible. When the aorta dissects itself--as in advanced syphilis or Marfan's syndrome--it's really, really bad. Rupture and exsanguinate (isn't that a great word? Better than 'bleed out,' in my opinion) in a matter of minutes bad.

7. Waiting for 45 minutes at the reproductive endocrinologist's office with only a People mazagine for company reinforced several things I already know about myself:
a) I think those over-sized sunglasses are a horrible, horrible trend, mostly because I associate them with Paris Hilton and Mary Kate Olsen. Also, they make people look like bugs.
b) I am a fundamentally impatient person. I have a need to be doing SOMEthing at all times. Maybe the Universe is teaching me to be more chill; I don't know.
c) I am out of touch with popular culture, and this does not bother me. I know who Jon and Kate are solely from check-out-stand magazines; I do not care about their family because I have other things to care about, and also because I am strangely immune to the 'cuteness rays' children emit. I spend evenings reading textbooks and writing sonnets rather than watching TV. Does this make me a better person than someone who watches Wheel of Fortune or streams cat videos on YouTube? Yes. Yes, it does.
d) There is no way to make a gyn exam not suck. There are, however, ways to make it suck less--and the rules for an easy exam are surprisingly similar to the rules for good sex. To the patient: relax. Speak up if something hurts. Breathe. For the doctor: Go slow. Explain what you'll be doing before you do it. Warm the speculum, or use a plastic one. Have lube handy. Don't be in a rush, but don't hang out in there forever.

More on Fat Acceptance...

Great article on eating disorders in the Fat Acceptance movement from my absolute favorite magazine, Bitch: Feminist Response to Pop Culture.
An article which begs the question, what exactly makes an eating disorder? Obviously it's a subjective diagnosis, whether you're talking about anorexia or binge eating disorder (yes, there are 'physical,' objective indicators of eating disorder status...a BMI below 17.5, or amenorrhea for more than 3 months for anorexia, for example) but then again, even the DSM-IV includes "overvaluation" of weight as a symptom of EDs. Think about that. In 2009, in the United States, one could reasonably argue that most women 'overvalue' their weight. Not because we're stupid or shallow or have a diagnosable eating disorder, but rather because that's what we're trained to do from elementary school on. Despite the positive spate of articles in teen-oriented magazines like Seventeen, there are still 'Summer Tone-Up Specials' published every May, showing 13 year olds that the best (and perhaps only) way to be a real woman is to watch those calories and do 100 crunches a day.
We have a slew of television shows like 'Bulging Brides' (I almost fell off the treadmill at the gym when I saw that title a few days ago) and 'The Biggest Loser' that focus exclusively on weight loss. Magazines at the check-out stand offer ways to drop 20 pounds in a month--assuming that every woman wants or needs to lose the equivalent of a small child--then, in another article a few pages later, exhort women to love themselves whatever their shape. Then, in the 'Health' column, another admonition that a body fat percentage over 20 means you're headed for an early, deep-fried grave. The whole mess is--well, a mess.
The primary point is that eating disorders occur in people of all shapes and sizes--something that most people would benefit from knowing. Officially, anorexia requires a certain percentage of weight be lost--yet I've known 'normal' and overweight people who followed profoundly restrictive diets. For a period during college, I was running ten miles a day and eating 600 calories--but it wasn't until my weight plummeted past 100 lbs that I was 'officially' anorexic. Bulimics can be any weight. Someone can binge-eat and weight 80 pounds, or 380. The fat acceptance movement is right on in encouraging people to care for their bodies--but an eating disorder, whether manifest in starving or bingeing, is profoundly unloving. For a woman attempting to heal that damage to be rejected by the very movement that purports to champion body-love is both counterproductive and disappointing. Exclusion and derision hurt, no matter what the 'political' motivations.

Cool stuff learned in class this week

1. If you have 2 boys, roughly 13 years of age, show up together in the ER with symptoms of atropine poisoning (anticholinergic or antimuscarinic poisoning): Odds are good--ie, 90%--they heard from someone--like a 14 year old boy--that it's possible to get high by smoking a plant called Jimson Weed. The bad news is, it contains alkaloids related to those found in Atropa belladonna (otherwise known as deadly nightshade) that will make your mucous membranes dry, make you unable to pee, cause hyperthermia (ie, high temperature, but not mediated by the cellular messengers that usually cause fever), and make you kind of delirious and crazy. It's a high, sure, but it's not the nice sort of high you get from a Purple Haze or a White Widow (names, apparently, of carefully cultivated and very expensive varietals of Cannabis sativa. Ahem. Seriously, I read about it in a New Yorker article. And then learned about 'Afternoon Delight' from Arrested Development. Aside: I really don't know why marijuana isn't legal. It's exponentially safer than cigarettes, alcohol--or, for that matter, aspirin).
2. Two teen girls who show up together will probably exhibit an anticholinergic toxidrome related to motion-sickness meds (hey, if you take enough Benadryl or scopolamine you can get high!) or a sympathomimetic toxidrome (ie, be speedy, with pounding hearts and anxiety) related to drugs like amphetamines taken for weight loss.
3. There is a drug called Narcan which exists to bring people out of heroin-induced comas, but according to the lecturer, "People are usually pretty pissed off when they wake up, because you've undone the nice high they paid for."
4. There is a drug called Flumenazil that exists to undo benzodiazepine toxicity, too, but it's used much less often, and for good reason. If someone's been abusing (or even just taking regularly, as one might for insomnia or anxiety disorders) benzos, they'll be kicked into withdrawal, one sign of which is seizure. And what's the first-line treatment for seizure? Benzos, only know you can't use them, because you've blocked the receptor. Oh shit.
5. Despite having to memorize lots of drugs and mechanisms, pharmacology is pretty damn cool.
6. Pediatric neck masses are almost never cancer. In older adults, they almost always are.
7. If someone says they feel like they're 'spinning,' 90% of the time they have an inner ear problem.

A physician-to-be looks at Fat Pride

There is a movement called Fat Pride. Marilyn Wann, the author of a book of fat activist essays entitled "Fat?So!" is widely considered to be at the forefront. It supports taking back the word 'fat,' just as the gay rights movement has taken back 'queer,' stripping it of its shameful and painful connotations. As one of my fat activist friends explained to me, "I'm fat. So what? I could say I'm Rubenesque, or generously proportioned, built for comfort and not for speed. But to the rest of the world I'm fat. Why dance around it?"
At a medical school, of course, we are taught that fat (dietary or bodily) is anathema (for those readers who majored in biochemistry and haven't read anything but Cell since sophomore year, anathema means really really bad). Virtually every lecture touches upon it in some way, from last year's biochem lecturer who seemed almost pathologically obsessed with saturated and trans fats (she cut one of her favorite baked goods out of her life entirely when she discovered they contained what I believe was 2 g of trans fat per serving--but then I speak as the person who has a hang up about fiber, which is no less pathological, and has me tallying my 25 grams a day in my daily planner)...to this year's pathology talks on cancer, in which dietary fat intake presents significant increases in malignancy risk. Obesity is a risk factor for cancer, for heart disease, for type II diabetes...yes. This is true. But there are other findings which are not discussed, and furthermore--and more disturbingly, to my mind--there is an atmosphere of...distaste for the obese that permeates our education, and which has no place in the training of future caregivers.
For one (yes, I should cite the study. Go to pubmed, and I have no doubt you'll be able to find it. I know saying 'A study said' without further citation is the gravest sin a scientist can commit. Mea maxima culpa) when overweight but cardiovascularly fit, exercising individuals and 'normal weight' but unfit individuals were tracked for seven years in a longitudinal study...the normal weight couch potatoes were at a higher risk of death. Interesting. Granted, in a social milieu that fosters sedentary life and cheerfully offers to Supersize everything, poor eating habits and inactivity often come together and produce someone who is unhealthy--and who also happens, through the normal workings of thermodynamics, to be overweight. But are all overweight people snarfing deep-fried Oreos and calling Guitar Hero their 'cardio for the day'? Of course not. Look, Grasshopper, and you will see...shades of grey. Yes, I know I spelled it the British way. I like that way better.
As for the distaste for fat people--which we medicalize and sanitize by calling 'overweight or obesity'--that is a much more malignant issue. My medical school class is not a cross-section of society by any means, perhaps most especially (and I find this intriguing) not in terms of body habitus, nor in health habits. Almost a dozen of us--out of 124--ran the St. Louis Marathon last year; many others ran the half-marathon. Today in class, I watched the snacks people were eating: four apples, one bag of carrots/celery, one bag of trail mix, a banana, and numerous diet Cokes. And as for body size, well, we are FAR below the widely cited "1 in 3" obesity statistic. Approaching, in fact, 0%. Perhaps that makes it easy for us to think of the obese as "them": it's something that happens to other people, something from which we (with our daily workouts and carefully planned 1800 calorie, low fat, high-fiber diets) are saved by our superior willpower.
I worry about this.
I worry that this will create physicians who think that nagging, insulting, preaching or condescending will get people to lose weight.
I worry that this will create physicians who think 'fat people' are to blame for all their health problems and are undeserving of sympathy and empathy.
I worry that we haven't found a way to help people who want to lose weight but can't, and that this may be partly because we think fat is a moral failing.
I worry.

Love/Hate

It's that time of the month again...time for things (and people) that piss me off, the Medical Edition! And, because I'm trying to remain positive this year, there will be an equally important Things I Like section.

Things That Piss Me Off
1. When a doctor orders six separate blood tests, and they are tests that need to be done on different Vacutainers of blood, so that I have to give six tubes of blood instead of one. This isn't anyone's fault, per se, it's just one of those things that can't be helped. Also, when the phlebotomist has a hard time finding a vein and rather than WITHDRAWING the needle and trying again, just digs around under the skin...it's an awful feeling. I've drawn blood before, and I've had lots of blood drawn, and it's easier for everyone just to retry.

2. The paper gown. Just when you thought it was impossible for the hospital gown to get any draftier or less comfortable, they've traded in that cloth gown (which, despite being 3 sizes too big, at least provided you with a sense of being somewhat clothed) for one made out of Charmin. No, not even Charmin. Whatever the Aldi brand of toilet paper is, in 1/2 ply.

3. The fact that, despite being gay and despite having been celibate for longer than I care to mention, one of the first several questions any physician will ask me is, "When was your last menstrual period?" Even if I come in for chronic sinusitis. I'm not pregnant, I promise. Or, as I told the X-ray tech the last time I had a chest X-ray, "If I'm pregnant my girlfriend has a lot of explaining to do."

4. That the only medication that has considerably improved my insomnia gives me a hangover effect that keeps me from full consciousness until about noon the next day. During last year's finals, I was 45 minutes late for our Genetics exam because said drug kept me from responding to the alarm. I cycled through 2 anxiety attacks on the way (run!) to class, and got the extreme evil eye from the professor. It's nice to make friends with faculty members who are also in positions of authority within the school at large (ie, if you're going to be late for someone's exam, try not to make it one of the Deans'. Ooops). Thanks, Seroquel!

5. Male gynecologists. I'm sure they're nice people. I know several. I'm probably being sexist. But I don't want a Mormon bartender, I don't want a mechanic who's never driven a car, and I don't want someone without breasts or ovaries examining mine.

Things I like
1. Bandaids with cartoon characters. Call me childish, but Hello Kitty bandages really do make those minor abrasions hurt less.

2. Zyrtec. Can I get a hallelujah from all those with allergies? Zyrtec has made spring and summer enjoyable again. No, I'm not getting paid to say that.

3. Eugenol, or oil of cloves. I had a dry socket (otherwise known as the most painful condition humankind is heir to, outside of childbirth and kidney stones) once, and within seconds of having it packed with eugenol-soaked gauze, the pain was gone. I wanted to kiss the dentist on his big bald head.

4. Ativan. The ultimate anxiolytic, though its usefulness is limited by the fact that it generally leaves me too gorked to perform daily functions. It seems to work as most benzodiazepines do--ie, on the assumption that you can't have a panic attack if you're unconscious.

Fun stuff: Wegener's granulomatosis.

When someone has had what seems like allergic rhinitis for fifty thousand years, despite pouring on the Flonase and all but mainlining cetirizine, one begins (if one is as obsessed with rare diseases as I am) to think about Wegener's granulomatosis. It's an inflammatory condition--not a cancer, not an allergy--that eventually leads to extensive vasculitis (ie, inflammation of the blood vessels). It can cause problems especially in highly vascular organs--kidneys and lungs particularly. On microscopic examination, clumps of white blood cells are visible: granulomas. Hence the name.

However, there's now pressure to rename the disorder, in part because eponyms don't actually tell you very much about the condition itself (though I have to say the alternative proposed in this case--ANCA-related granulomatous vasculitis--doesn't tell me much more) and also because of Dr. Wegener's past. Apparently he was wanted by Polish officials after the end of WWII. Apparently he was, for at least a short period of time, associated with the operation of the eugenically-minded killfest that was Lodz in the late 30s.

How do I know this? Because the aforementionedly awesome Dr. W. brought it up in class.
"Haven't you heard Dr. L's tirade about this?" she asked one of the co-instructors. "I remember hearing him go on and on about this Nazi granulomatosis." Which made me imagine clumps of white blood cells wearing little olive drab uniforms and goose-stepping all over the body.

Excessive Awesomeness

I thought our first day back in the saddle with 'Practice of Medicine' would be the same old routine. Nope. The coursemaster (actually, coursemistress...is it more or less PC to call her that?) contributed greatly to the overall awesomeness. So sharp she might cut somebody--and she also appears to have an exquisitely low bullshit tolerance, so she might cut somebody for being inane, too. Which, I will be frank, I like. There was a brief discussion of how to comport ourselves out on the floors, including the admonition to take out the facial piercings and cover the tattoos. Also--and you'd think this wouldn't be an issue at our institution, but alas, it apparently comes up--to be well-groomed and hygienic. To quote Dr. W (all my Ithaca pals are laughing because that's the name of the Wegmans store-brand diet Dr. Pepper I drank by the liter all through college):

"Every year a resident gets the dubious honor of talking to one of the house officers about grooming issues. My favorite ever was, 'J, please wear underwear.' You do not want to be that person."
Mother of God. I can't even imagine the situation in which that talk became necessary. I can see "please don't wear any more leather miniskirts," I can see "please wear an appropriately-sized belt to prevent us seeing your 'Sizzling Scarlet' lace g-string," I can even see "If you're going to wear short skirts, cross your legs when you sit down." But...no underwear? In a hospital? Definitely not hygienic.

and so it begins.

As it turned out, today's orientation chat was in fact a mere 30 minutes in duration, due in part to the absence of one of the deans (who was settling her daughter in at college...which, actually, is pretty sweet and indicative of good priorities). Additionally, it was very un-fire and brimstone: the admonition that yes, there are grades this year, was followed by an assurance that it is indeed possible for everyone to receive an 'Honors' grade in every class, as there's no curve. The acknowledgment that Boards will be upon us in less than a year's time was alloyed with the assurance that if we take them in June we'll have more than ample time to study, and a gentle chiding that it really is in our best interest to take them then (although our school, strangely, does not require us to take the USMLE; you'd think they'd want everyone to go get liscensed, but whatever) because you're REALLY not going to remember that stuff about the pentose phosphate pathway three years out from biochem. We have to register, or more accurately register TO register, in September. Getting your test date set is apparently a multipartite and esoteric ordeal, which may or may not involve setting up a bank account in the Canary Islands and/or painting the last four digits of your SSN in blood on the carpet of the registrar's office at midnight (bonus: Since this IS a medical school, the blood doesn't have to be your own, as long as you use universal precautions while handling it. As a vegetarian I'm allowed to use beet juice).

The laid-backness of the talk (which did not meet my expectations--but in a good way) was primarily due to the fact that it was Dean K giving it. All our deans are pretty chill, and indeed in all cases nice people that I wouldn't mind having drinks with, but I'll just come out and admit that I think Dean K is the bee's knees. When I've had occasion to deal with her, she's been fantastic. She's unbelievably helpful and grounded; one of those rare people that exudes NICE while also giving the impression that she is exhaustively competent and would not hesistate, if it became necessary, to kick serious ass (which here comes in the guise of the 'professionalism concern form'): in fact, not a bad role model.

The real deal starts tomorrow. Pharmacodynamics. Frankly, I'm a little scared by the sheer quantity of material it looks like we'll be covering in lecture tomorrow. We're in the army now!

Parenthetical remark count: 5

Things'll be different, baby. Promise.

So the new school year starts on Monday, and tomorrow we have our one and a half-hour 'second year orientation,' which the class ahead of us has said is basically 90 minutes of having the fear of God put into us...ie, this year we have real grades, this year even more is expected of us, no more messing around, no more procrastinating and trying to cram everything in two days before the exams, etc. A sort of preemptive strike against laziness; a preventive spanking.
Problem is: this is what I have going through my head 24/7, in stereo and at a volume setting of 11 (out of 10). Do I really need to have the shit scared out of me to do a good job? Especially when I'm already, so to speak, flowing in that direction? Now we have Honors, High Pass, Pass and...*Not a Pass* as grading options, rather than the previous Pass/Fail. Of course, I'm going to shoot for all Honors, but do I need to go to Gunner Attitude Boot Camp tomorrow to get ready for the coming year? Maybe I'll have a little Xanax before I go... Am I high strung? Pas de tout.

And this year it'll be different. Not so much with the studying (I studied a fair amount last year, and didn't generally put things off...just tried to stay on track, rather than trying to learn a semester's worth of material in three days like some people I know...who shall of course remain nameless), but with life. A balance. Social activities, studying, exercising, and perhaps most pertinent for those reading this: blogging. I'm going to update this site, if not daily, then at least 4x a week. Hopefully there will be hilarious hijinks to recount, poignant moments to share, and my strange mix of hippy-dippy idealism and cynical misanthropy to vent. Join the fun!

This first 'block' of courses includes
Pathology, ie: 'When stuff goes wrong,' or 'Looking at the process of disease' or 'The Microscope's Revenge: The Return of Histology--this time it's nasty.'

Pharmacology, or 'Yes, we can make even DRUGS monumentally un-fun. Who remembers what gets processed using Phytochrome 450? Or perhaps more trickily, what doesn't? Hands? Tell me the difference between adrenergics and cholinergics and be smart about it!'

and Otolaryngology, or "The only lecture you're really going to remember is the one about things kids have stuffed up their noses."

Why does everyone hate vegetarians???

So I've been invited out for dinner tomorrow night, and the woman doing the asking sent me a list of possible locations. Being the Type-A foodie that I am, I of course check the web sites (and pdf menus--what did those with food neuroses do before the InterWebz?) of all the restaurants and find that 1) They're all pretty expensive, which makes me...uncomfortable, and 2) My menu options are sorely and sadly limited (though not, to be fair, at the Indian place she mentioned).
What is it with Americans and the insatiable meatlust? Grrr.

Abstinence Only?

So, thank God, Bush is no longer in the White House...but abstinence only education is still mandated in much of the US by state law. There are still abstinence-only government sites up on the web, too...the most interesting of which is 4parents.gov, which offers help in talking to your kid "early and often about waiting to have sex." Waiting till when? Til 18? 21? Whatever the age of consent is in your state (it's 14 in Missouri, and in some states as low as 12, to which I can only say...ew)? Til they're paying their own mortgage? No, silly...until their state-sanctioned, Judeo-Christian marriage! Which means that if I'm going to wait to have sex, I'll have to hold out until I have enough money to get my ass to Vermont (oh, wait--I could just go to Iowa, but then I'd have to live there permanently, because my marriage wouldn't be recognized in Missouri! Oh Joy!).

4Parents.gov also talks about the 'emotional' risks of early sexual involvement...for instance, girls who have sex, do drugs or drink are more likely to be depressed (first, this seems like a chicken/egg situation, and second, um, it seems a little...odd to put doing meth and doin' the nasty in the same category). Obviously, a middle-schooler isn't emotionally prepared for the sequelae of going all the way...but they're still going to, and perhaps it would be better to talk about REALISTIC ways to protect themselves--being assertive about their boundaries, using condoms and birth control, having sex with peers rather than falling for exploitive 'relationships' with older teens/adults--than to act as if the Magic Wand of Abstinence can make all these issues disappear.

Speaking of, apparently Bristol Palin and Jamie-Lynn Spears are working with the Candie's Foundation (I thought they sold shoes...WTF?) advocating--I kid you not--abstinence. Because, you know, it worked so well for them. So here's the real deal: Abstinence-only education and signing of chastity pledges generally does delay the age at which teens have their first intercourse (obviously we're talking hetero, lingam-in-yoni here). BUT when they do finally break down/give in to Satan/get coerced/whatever, they're less likely to use protection. And y'know what? The fact that you waited until you were 17 doesn't make you any less pregnant or any less infected if you don't use a condom.

The Level of Discourse

During our most recent "Practice of Medicine" small-group session, we were discussing interventions for a hypothetical obese pediatric patient. We started off OK, as we generally do, but it only took a few moments for people's real feelings about the issue to make themselves apparent. Let me make something very clear: I love my classmates, I really do; and I have great respect for the vast majority of them. However, even estimable people sometimes believe (and vocalize) less-than-estimable things.
Within ten minutes, we had gone from using the terms "obese" and "overweight" to 'fat;' within fifteen, 'fatty' and 'Porky' had been thrown out (I regret to say that our faculty preceptor was among those to use those epithets, though admittedly in jest). I felt like my head was going to explode, showering my tablemates with gray matter, if I didn't say something.

I raised my hand, and as calmly as I could, said that I would explain the need for change to the patient/family by emphasizing the importance of healthy eating habits and healthy exercise routines, and not necessarily focusing on weight or a need to slim down (In fact, in all but a few cases, it's best to try and keep overweight children's weights STABLE, and let them grow into their 'extra' weight--ie, let a 100 pound fourth grader become a 100 pound sixth grader; no weight loss necessary). I also said, through more or less clenched teeth, that I was not entirely comfortable with the level of discourse in the room, and that placing undue emphasis on weight rather than healthy behaviors could encourage or 'set off' an unhealthy relationship with food, particularly in girls. Another student (a guy!) agreed, and mentioned self-esteem issues, eating disorders, cutting--all those uglinesses that derive from body hatred. "We're going downhill fast!" the preceptor exclaimed, to general laughter, at which point I all but jumped on the table and said,
"We're acting as if precipitating an eating disorder is a remote possibility, as if an authority figure's judgement of a young person's physique carries no value. It does. Yes, there is an obesity epidemic. One in three kids is overweight. But by the time they reach college age, between one-tenth and one-quarter of women have an eating disorder. This isn't coming out of left field."

After this the preceptor sort of propitiated me, saying that in his experience girls with eating disorders actually start out slightly overweight. We reined ourselves in a little bit. I was still struck, however, by how glibly we treated what is for many people a lifelong and seemingly unwinnable struggle against weight issues, and how we assumed that obesity is largely the result of laziness and gluttony--how quickly we turned a medical issue into a moral one, patting ourselves on the back for eating five servings of veggies a day and deriding those who cannot, as we can, run five miles a day. I wanted to say that actually, having had an eating disorder for more than half my life, it would be much healthier for me to have carried around an extra twenty or even thirty pounds than to have done all the things I've done over the years (and still, unfortunately, do sometimes) to control my weight--things that have lead to arrythmias and seizures, things that have screwed with my reproductive and skeletal systems, and most importantly, with my brain. As students at one of the top medical schools in the country (as we are repeatedly reminded), we have a responsibility to become competent physicians not only in the realms of diagnosis and hard science, but in the realms of ethics and communication as well.

A to Z of Rare Medical Words

Words I didn't know before I started medical school...in alphabetical order (kewl).

anastamosis-communication between blood vessels

basilar artery-artery located (surprise!) at the base of the brain

Christmas disease-no shit, there really is a Christmas disease. Wouldn't it suck to have to tell someone, "Yes, you have Christmas disease...not Chanukah disease, not Ramadan or Holi disease...Christmas disease. Well, there's your present. Happy holidays." It's a sex-linked hemorrhagic disorder.

decidua--not related to trees; it's a kind of tissue found in the uterus.

enkephalin-a naturally occuring opiate, a la the endorphins.

falx-a sickle-shaped structure, a la the falx cerebri (look it up).

gastrocnemius-the big muscle in your calf.

hapten-a small, separable part of an antigen (look it up again).

imbrication-layers of overlapping tissues in a sutured wound. Use it in an everyday conversation and I'll pay you twenty dollars.

jake leg-paralysis caused by drinking improperly distilled liquor (not related to jimmy leg, which means--I dunno, actually, but it sounds bad. Oh, wait--according to the internet, it's Restless Legs Syndrome).

kallikrein- a vasodilatory peptide, ie, a molecule that dilates blood vessels.

labrum-a ring of cartilage attached to the rim of a joint. But doesn't it sound like a dirty word?

mediastinum- the space between the pleura of the lungs, where the heart is. So, y'know, home isn't where the heart is--the mediastinum is where the heart is.

natriuresis- When you piss away salt. Ie, when your urine contains too much sodium.

obtunded-passed out, to the extent that you don't feel pain when exposed to noxious stimuli.

palmaris longus- a superficial muscle of the forearm.

quinsy- an abcess around the tonsils. Seriously, there aren't a lot of words, period, that start with q, let alone medical words I didn't know before.

reamer-a dental instrument. Yes, it is in fact called that. Didn't you always feel like you were getting reamed at the dentist's?

Saint Louis encephalitis- a viral encephalitis named after the city in which I am now going to medical school. Normally you can't get that kind of deal without getting your MD in a tropical location.

tardive-the adjectival form of lateness. A fancier way to say tardiness-ness, I guess.

unctuous-fatty or oily; One of the side effects of Alli is unctuous anal leakage.

vasa vasorum-literally, vessels to vessels; the small blood vessels that supply the walls of larger arteries or veins.

Wharton's jelly-a form of connective tissue in the umbilical cord that, obviously, has a jellylike consistency. Impossible to eat on toast without vomiting afterward.

Yaws-a tropical infection of pretty much every tissue in your body, caused by a spirochete. Ew.

Zonule of Zinn- double credit! The suspensory ligament of the lens of the eye.

Hope you had fun! I know I did!

Snoezelen!

Snoezelen rooms have recently come to my attention (actually, they came to my attention a year or so ago when I had a woman from my church tell me she thought I had a sensory integration disorder...make of that what you will, but there is the fact that I tend to be very sensitive to hyperstimulation. I do OK with things generally, which is good since 3rd and 4th year will basically be defined by 'hyperstimulation.').
They are simply these soothing, gentle rooms designed to help chill out people with developmental disorders, with a smorgasbord of subtle, calming sensory experiences available for the client who's using the room. They've been studied in this capacity, and actually appear to work for autism and Alzheimer's Disease (though of course a double-blind randomized controlled trial isn't possible in this case, which leads me to wonder if perhaps we don't need an alternate paradigm for assigning validity to studies; not a complete overhaul, just some new ways of looking at things that aren't so "pill vs. placebo"-centric). I really want one, or to spend some time in one, maybe...There are dim lights, but also things to look at--from my webcrawling it appears tropical fish tanks are popular--tactile experiences like padded walls (no jokes, please), pillows, satin and chenille throws; auditory experiences like soft music or the sound of rain or a babbling brook; Sometimes it's even possible to incorporate smells.
In the meantime I suppose I'll make do by lighting a tuberose candle, covering my lamp with a scarf, and wrapping myself in my fleece throw. It's not the same, but it'll have to do.

quitting, and the placenta.

One of my classmates was able to witness the miracle of birth today ("Not as much screaming as I expected" was the general jist). What really freaked her out was not the birth itself, but the afterbirth--that's right, the placenta. "It was just this big...thing," she said, her eyes wide. "This mush. It was this big--" she spread her hands, as if demonstrating the size of a prize catch--"And just purple-y and huge and..." Obviously a terrifying thing.

I discussed this with my roommate, a NICU nurse, who concurred. "They aren't pretty. They never show it in movies, either," she said, her brows furrowed. "It's always just, yay, a pretty baby. No placenta. Sometimes when there's something wrong with the baby or the mother, they send it along to the NICU in a bag," she added. "Usually they're nice about it and put it in a black bag so we don't have to look at it. When the fellows come they're always really excited about it, too, because then they can send it to pathology." She shuddered.

The word itself comes from the Greek for "plate" via the Latin for "cake," both emphasizing the fact that the placenta's pretty flat. I've tried several times to link an image, but screw it. Look it up on Wikipedia; there are several images, some gorier than others.

I am updating in part to fill the time I would ordinarily be spending smoking. Also because I have been relentlessly badgered by a certain person whose name starts with a G and ends with an inder. Oh! So, a random recap of today's events, which may be elaborated in a later post:

Today we had the only dental lecture we will ever get in med school. Saw many images of periodontal disease, thrush, malocclusion and canker sores. Take home message: Brush. Floss. Use fluoride rinse if you have to. Just because you're smoking meth every five minutes doesn't mean you can't maintain a basic oral hygeine regime (although admittedly there are other factors at play in the development of 'meth mouth.' If you've never had the pleasure of seeing manifestations of that malady, please do google it, though not if you are eating, have recently eaten, or are planning on eating again, ever). Other take-home message: don't be afraid to get a dental consult, because as a physician one of the few areas of the body you are NOT required to know jack shit about = teeth (Note how I used the equal sign to avoid making a mistake in subject-verb agreement in the previous sentence. Is? Are? Is 'teeth' the antecedent or is 'one'? Because teeth are, but one is. Sorry. Grammar Gestapo.)

I wore my lucky turtle socks today, a gift from a college roommate, and subsequently discovered I'd gotten an honorable mention in the William Carlos Williams Poetry contest (a poetry competition for medical students). Now I just have to get the registrar to affirm that I am, in fact, a student at Wash-U med--because, according to the woman I spoke to on the phone, there was an 'unfortunate incident' several years ago. Erm. Go lucky turtle socks! My precious...

As far as quitting goes, I have my patch on. I have been chewing gum like crazy. Sugarless gum. The gum that warns you that "excessive consumption may have a laxative effect on susceptible individuals." Apparently I am a susceptible individual. Apparently I have also been consuming excessively. And now I am doing other things excessively as well. So that's fun.

Honestly, I think the patch is giving me a bigger dose of nicotine than I got when I was smoking, because I feel really revved up. For instance, I'm not tired right now at all, and I'm normally positively geriatric when it comes to bedtime (at least since I started taking Seroquel, the only thing that has EVER worked to KO my chronic insomnia...though I know one person in my class is achieving similar feats with codeine cough syrup. Meh. There have to be SOME benefits to being sick; I say ride the gravy train as far as you can if you're unfortunate enough to come down with something nasty). Also. Since the PI I wrote to earlier this month hasn't emailed me back, I am now expanding my horizons and sending out my CV to other PIs (that's 'principal investigators,' or 'people who are kind and generous enough to let me come work in their lab for the summer'). Also. I have been cunningly crafting Valentines all week and will spring them on the unsuspecting in the days to come.

Yesterday I had another MRI, of my ankle this time. Stress fracture. Big fun. Hopefully all will be healed in time for the marathon in April. If not, I may have to do the half instead, and I will be disappointed. Sad face.

Ok, I'm gonna do ID instead.

What's ID, you ask? It's more than what I get asked for every time I want to see a rated-R movie or buy a pack of cigs (My for-real, I'm in an American Lung Association sponsored smoking cessation class quit date is Feb 3rd--wish me luck. In the interim, the woman at the corner store-- with what are apparently the early signs of dementia--asks me every single time, "What are you, in middle school?" No, ma'am. Just flat-chested and baby-faced. Moisturize, and you too could be mistaken for half your age!). It's Infectious Disease, y'all, and it's super cool.

Did you know there are more microbes in and on your body than there are cells that belong to you? So even if you're an atheist, or agnostic, or on a desert island...you're REALLY never alone. I know it's weird, but it's sort of a comforting thought. You, by yourself, are a community--an ecosphere all your own!

There are lots of microbes that live happily with you and don't cause any disease...it's called commensalism, or mutualism. Actually some bacteria even feed you--making Vitamin K in your intestines, for example. Others live on your skin and keep bad guys like MRSA (the nasty 'superbug' that's been in the news lately) from taking over...like your own little bacterial bouncer patrol.

And even bad bugs--enterococci that cause gastritis, para ejemplo--have some mechanisms of action that are truly amazing (sort of like how you hate the Bond villain in every movie but are frankly amazed at the intricacy and detail of his/her evil schemes): E. coli can actually get INTO your bladder cells and chill out there, evading detection. You get treated for a UTI, all the 'outside' bacteria are wiped out, but then there are these little 'seeds' of e. coli lying dormant-ish, waiting, and then BAM! Even though you haven't been reinoculated (ie, you haven't gotten more bacteria into your bladder by having sex and not peeing afterwards, or wiping back-to-front, or wearing tight pants, or whatever else is on the 'not-to-do' list these days) you're reinfected. Whoa. Take that, Mr. Bond.

Also, staphylococcus aureus is named that because 'aureus' is from the (Latin?) root for gold...y'know, Au? Remember the periodic table, kids?...and when you plate them out, the colonies are a brilliant gold color that's frankly stunning. I know I'm going to earn some weird looks for this, but especially when they're plated on blood agar, the contrasting colors are spectacular. I'd put a picture of that up in my living room, with the caveat that no one be allowed to ask what it is.

PS--No, I'm still totally married to psych, but ID is definitely, undeniably enthralling.

It's the sarcasm patrol!

So this has been an awesome weekend.

Got an email from the doctor saying, yeah, we need to do an MRI. To check for--no shit!--a brain tumor.
Had a respiratory physiology take-home exam.
Couldn't start my car Saturday because it was too cold and the gas line had frozen up.
Went outside today to discover that someone had broken into my f*cking car.
And this week looks to be like a baguette--long and hard (well, maybe not AS long, since it's only 4 days).

Seriously, God. Not cool.

Breasts!

Knew that would get your attention. Anyway, it always gets mine.
But no, this is not about mammary glands, not really. Instead it's about the respiratory exam, which we learned to do today, and the delicate art of intergender examinations.
When we finally got up to our practice rooms to attempt the arts of "inspection, palpation, and auscultation" on one another (that sequence has been effectively drilled into my head now--thanks, Dr. R!) the question arose: same gender dyads to practice, or opposite, or both? As the preceptor said, "I know that for practice's sake it might be better to pair off male/female...but for comfort's sake, you'd probably rather do same-gender exams, right? Well, you've got five more years of practice ahead of you, so for now let's stick with comfort and do same-gender pairs." It's odd; everyone in the class knows what my orientation is (I think) but to date this hasn't caused any awkwardness, for which I am profoundly thankful. It's hard enough trying to learn how to percuss and listen for inspiratory splitting without worrying that your exam partner thinks you're surreptitiously trying to cop a feel. Which, it goes without saying (and for once I'm not being sarcastic) I would neeeeeever do, for approximately 573 reasons, among them professionalism, integrity, the fact that a lot of the women in my class could kick my ass if I tried such a thing, and the fact that I'm really not into the whole sexual assault business.

I was surprised, but the guys actually seemed more uptight about the idea of examining women than we did about the prospect of being palpated by gentlemen (and in fact all the men in my practice group are what I would call gentlemen). "I mean, how do you do the exam...with women?" one of the guys asked. To which our preceptor--a funny guy who I am 99.9% positive is gay, and whom I thus had no qualms about allowing to demonstrate part of the exam on me--said, "Well, the breasts are always going to be there." We all laughed at that, but it's true; I've never really been conscious of it, because I'd only ever been on the receiving end of physical exams before, and with my 32AAs there isn't much concern about impeding the progress of a physical (though there was the nurse who took an EKG and left my gown wide open until I yanked it closed...I was not pleased), but breasts can be cumbersome when you're trying to do a cardiac or respiratory exam. You may have to ask a woman to lift or move her breast, or if she can't, gently do it yourself. We're just learning about all this, so we still get awkward and blushy and worry that someone's going to be pissed at us. By third year, apparently, mammaries will be mammaries will be mammaries. It's all in the approach, I guess, in how the body is constructed and understood from a cultural perspective (and medicine--medical school especially--is definitely its own culture).

Learning to laugh at my own stupidity--and Microbes!

So I slept essentially...not at all last night (ok, 5 hours) and that was from 4:30 to 9:30. That may not seem like much of a shortcoming to you late-night IMers and Conan O'Brien watchers (yes, I realize I just sounded like a geriatric patient, and secretly I am a 87 year old woman--you kids quit playing grabass on the lawn!), but I've got me some bipolar disorder, and I need my damn sleep. So I was not running on all however-many cylinders today, as became immediately (or, unfortunately, not-so-immediately) apparent when I went to pick up some essentials at the grocery store today. Never mind that the grocery store is kind of a fraught place for me, or that I have a rough time actually picking things up and putting them in the cart, or that I always feel like I'm in 15 different people's way...beyond all that intrinsic neurosis, I got to the check-out counter FINALLY, and when all was said and done...I didn't have my credit card with me. Got it out of my wallet to do God-knows-what with it and never put it back in, and had all of $7 in cash with me. So I did the whole stammering/turning red/sweating/sympathetic nervous system in overdrive thing, y'know, where you wish the earth would open up and swallow you down to the bowels of hell where at least you could hang out and drink absinthe with Oscar Wilde. So I muttered an apology and all but ran out the front door, my face a color somewhere between "rose" and "carmine" in the Martha Stewart interior decorating palette. Once I was home and finishing the last of a bottle of merlot I could look back at it and laugh, because it is sort of a ridiculous situation for a person who's obsessed with doing everything perfectly and never incoveniencing anyone to find herself in. Maybe I'm learning, little by little, to laugh at my shortcomings--at least those that don't kill anyone (please, please, universe, don't let there be any of the other kind!).
Also, had Microbes today for the first time, and it was so utterly kewl. We got a pack of these Microbe Cards to augment our learning process...like Pokemon or sports trading cards, with images of the infectious fungi, bacteria, viruses, or parasites in question on one side and information (from epidemiology to diagnosis to treatment) on the opposite side. I'm really looking forward to getting together a microbe card playing league..."I play N. gonorrhea!" "I play Cipro!" or "I play Hepatitis C!" "I play interferon!" Gonna be a +3 infectious disease specialist by the end (Note: I have never actually participated in an RPG and thus have no idea what I'm talking about...except for the microbes. I kind of know what I'm talking about there, but only to such an extent that I can sound reasonably intelligent at cocktail parties and probably be very dangerous to actual patients, which is why I'm not yet allowed in the same room with them without an M.D. chaperone).

No fumare

No smoking in...Italian, maybe?
Did you know nicotine is more addictive than heroin by most objective measures?
I did. And I'm trying to quit despite that knowledge. I went cold turkey once before, in college, and didn't smoke for 6 months...then stupidly, oh-so-stupidly, started again.
So right now, as I'm quitting (not trying to quit--quitting) I could kill someone--maybe myself, maybe an innocent bystander--with a spoon.
And so I was actually on the edge of breaking down and going to the corner store to get some nic sticks/coffin nails/ciggies/fags/whatever you call them, only to find (yeah, ha ha ha, Universe, really hilarious) that my ID is temporarily MIA. So no dice. This, to me, is a coincidence--but it's also an example of the Goddess saying, "You promised you were going to quit. Now sit your ass down and do some deep breathing." What a lesson in surrender.
Mysterious ways, indeed. I can't shake the feeling that Divinity has pinched my driver's license. Luckily I walk to school.