And today...we learned the pelvic exam.

First, there was the pelvic exam, which was largely demonstrated via a video (with the sound turned off) which an Ob/Gyn attending walked us through. It was odd sitting in a room with all these other people looking at a projected vagina larger than the lecturer's head.
Things learned, and fun quotes:
"So a few weeks ago my eighteen year old son, who is very dear and who's just begun dating, came to me and wanted to know about women's menstrual cycles...specifically how regular they are and what the implications are. And so, after I had a coronary and grabbed him and shook him until his fillings came loose..."

The 'inspection' portion of the exam, during which you inspect and palpate the external genitalia, went on FOREVER in the video. Quoth both Dr. W and Dr. S, "Don't ever stare at a woman's vulva for this long. I have no idea what's going on with this video...also, when doing the pelvic or breast exam, DO NOT make any comments on the patient's appearance. Not even compliments. ESPECIALLY not compliments. Especially if you don't want to get sued."

Put lube on your fingers, lube on the speculum...lube it all up. It won't interfere with Pap smear results, and it will make everyone more comfortable.

"Don't open the speculum until it's all the way in. Because if you get it halfway in, tentatively, and then open it up...(Every woman in the room winces and gasps). Yep, that's right. Every woman in here knows it. And guys, just imagine having something rammed up your urethra."

Be careful if you insert your finger before you insert the speculum...don't try to have too much stuff in there at once. Quoth Dr S, "There is a finite amount of space in most women's vaginas."
This is true--it's not like Santa's sack in there. It's not a clown car.

I was astounded the male GU and genital exams were actually demonstrated to us live. More on that after the jump.

Just a note

I would just like to say a few things.
To the prof who put a picture of a puking pumpkin in the power point presentation on eating disorders: Real sensitive. You're on the list.

To my body in general: stop producing prostaglandins. To my uterus specifically: stop trying to claw your way out of my abdomen. It really, really hurts and makes it difficult for me to study.

To Amina, who taught me that the best treatment, if not cure, for dysmenorrhea is a combo of red wine, David Sedaris essays and Sade (Sha-DAY, the singer of 'Smooth Operator,' which I thought of every time someone mentioned the obturator nerve last year in anatomy...actually, I think of lots of inappropriate songs at inappropriate moments...for instance:
-Talking to one of my high school friends about how she finally stopped self-mutilating: 'The First Cut is the Deepest,' by Sheryl Crow
-When one of my acquaintances (who I didn't particularly like) got evicted in college: 'There's No Home for You Here' by the White Stripes
-Watching Ann Coulter on FoxNews: 'Evil and a Heathen' by...shit, what was that band that came to play at Cornell my junior year?
-Listening to an attractive member of the faculty discuss drug abuse and dependence: 'Addicted to Love'
-At the 'Get to Know your Administrators' lunch: 'Dean's Dream' by the Dead Milkmen
-Sitting in the lecture on treating sexual dysfunction: 'Limp' by Fiona Apple)

Damn that was a long parenthetical.

Oh, and to Fiona Apple, since I'm thinking of it: Thank you for your body of work. Please put out another album.

Great Quotes from Lectures Today...and a TV Show

"I am not giving up. I never give up...I'm...transcending the situation." -Sheldon, from 'Big Bang Theory' (How I've felt about the past...approximately...week.)

"We finished that lecture a little early, so should we take an extra long break before the next one? There might be other people coming...What? Ok then, screw 'em." -Dr Z

"No, you don't want to give lorazepam to someone who's already intoxicated. They have a tendency to stop breathing." -another lecturer

"The appearance of oligodendrocytes on section is mostly due to artifact...but we're just neuropathologists, so a reproducible artifact is good enough for us." -yet another lecturer

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.

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.*

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.

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.

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.

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."