Adventures in Child Neurology

>I often get asked questions about how tough it is to be in medical school with a wife and kids and most of the time the answer is, “not to bad, really,” but this week has been one of those where it definitely takes some juggling. On Tuesday, eleven-month-old McKenzie Rose had an appointment to get ear tubes put in on an outpatient basis. We were first on the docket and supposed to be at the hospital (not my school’s facility) where the procedure was to be done at 6:30 a.m. Of course, somebody had to be at home with the older girls. Their usual ride to school arrives at about 7:20. And once they are off, somebody had to stay with Manning. And as an addition twist, my four-year-old nephew, Parker, is normally dropped off at my house around 7:30 and watches cartoons until Angie’s dad, his grandpa, arrives about 7:50 to take him to his pre-school. This maneuver is required for Parker’s mom to get to work on Tuesdays and Thursdays.

Okay, no problem. I arranged for my Dad to come over at 6:00, I got the girls up and watching SportsCenter, and made sure they had lunch money. Angie tried to get McKenzie out to the car without waking her, as she had not eaten since 8:00 Monday night and could not have any food or drink due to the general anesthesia. Parker’s mom made sure that he would not be upset about having to stay with a relative stranger for his few minutes. Uh oh! Just as we were about to leave, my oldest, Morgan says she does not feel to well and when I try to give her some Children’s Tylenol, she starts retching. We’ve got to get going, so my Dad says he can handle the kids and we head for the hospital.
By 7:15, we have met the anesthesiologist and seen our ENT doc. McKenzie was pulled from Mom and taken screaming and crying to her unknown fate. By this time, Angie’s mother has joined us at the hospital. Her grandmotherly instinct brings her out for even the most minor of hospital visits. The whole thing lasted less than 30 minutes and an already awake McKenzie was returned to her mother. Once I saw she had done fine under the anesthesia, I returned home, leaving Angie and her Mom to wait out the hour’s worth of observation that the docs require. I came home, found that both older girls had been deemed to ill for school, by their grandpa and were basking in the glow of attention. I got Manning’s pump feeding started and headed to school. I had made arrangements for a friend to pick up my handouts but I actually made it to my first 9:00 class. It was a wild morning, but thanks to a great support system of family, we made it all work.

Only two more days of physiology lecture are left. After this week comes a two-week gauntlet of exams that will end a whirlwind M-1 year. It has been a great ride and I am sure that I will look back on it as one of the best years of my life, but I am looking forward to a summer of rest and relaxation!

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Another week has flown by leaving only four more in my M1 year. It is exciting to think that it is almost over, but I am also a little wistful. This ride is so much fun and I know it will be over so fast that I wish I could slow it down just a bit. There are really only two more “normal” weeks (if there is such a thing in med school) because the last two are devoted to finals and boards.

Our small group psychiatry met Wednesday at the VA. I quickly volunteered to be one of the two students to interview our first patient, who turned out to be a well-educated, middle-aged lady who was in an alcohol treatment program. She was quite talkative and our interview turned into something more like a conversation, as each question elicited a story and led us down a new path. It was also a little awkward to share the patient between two of us. We took turns asking questions so neither of us really got to follow the path we had in mind. Our allotted thirty minutes evaporated and we still had not gotten to all of the mandatory items on our interviewing inventory. The psychiatrist in charge, seated behind the patient, pointed to her watch, while I nodded and tried my best to look like I was carefully noting each detail of the woman’s narrative. It all seemed to end so anti-climatically. While I had not really played this scene in my mind out beforehand, now that the interview was being pre-maturely aborted, I felt like we were being short-changed. It was no longer just a required exercise that I needed to log, but a chance to do something for this lady.. We were talking to someone with a real problem and it seemed like we should go ahead and try to help her as long as we were all here and everything was going so well. I thanked her for coming, and wished her well, and then she was gone, whisked back into her 28-day program, probably never to be seen again by any of us in the room. Our group leader then critiqued our “performance” with the main shortfall being the fact that we did not get to all of the pertinent information. Neither of us had asked about a medical history, and we didn’t ask the all-important question of whether she had ever considered suicide. (She had been diagnosed as major depressive also.) Our psychiatrist leader puts a lot of emphasis on this question.

The second patient was a middle-aged trucker with a crack cocaine addiction. The two guys who interviewed him had a problem in direct contrast to ours. Their patient would answer each question with as short a response as possible. While our time flew by, theirs seemed to drag. I am sure it seemed even worse to them, as they had to strain at times to come up with questions to break the awkward silences. Eventually the real doc rescued them by asking some questions herself.

As we wrapped up the session, I was still troubled by the way things just seemed to end. I don’t think either of these patients was any better off for the experience we had just gone through. I don’t know if it was her experience or just cynicism, but our psychiatrist gave me the impression of being jaded to the plight of these individuals. This will be one of the tough things to face in medicine … the sheer numbers of people who like Thoreau said, “lead lives of quiet desperation.” Kind of a bummer.

Speaking of bummers and cynicism, I had another jolt of it today. My 11-month-old daughter McKenzie has been battling chronic ear infections and we had an appointment today to see a local ENT about putting tubes in her ears. This doctor has put tubes in my oldest daughter’s ears twice and also did an adenoidectomy on her back in 1997. We think a lot of him and he always shows a personal interest in us. When he learned that I was in medical school, he promptly told us that he would bill our insurance only, and if we got a bill from his office to throw it in the trash! Ah, the wonderful concept of “professional courtesy.” He examined McKenzie, who promptly began screaming like a banshee when anything came near her ears. I had to pin her down just to get the tympanogram readings. We set up an appointment to have the tubes placed in two weeks and as we were shaking hands with the doctor he told me, “Mark, you’ve really picked a bad time to enter the field.” He was referring to the stifling legal climate that is currently a hot political topic in Mississippi. There has been a large increase in huge judgments against physicians and it seems to be open season for the trial lawyers. There has been a major push to get some tort reform pushed through the legislature, but that has been a hopeless cause, with the majority of state lawmakers seemingly either trial lawyers themselves, or beneficiaries of the same. Many rural practitioners are abandoning the ob-gyn portions of their practice and other high-risk areas, due to inability to pay their malpractice premiums. It is becoming a huge problem and it seems many local doctors are just fed up. Our doctor told me that he wouldn’t see patients who were family members or worked for a plaintiff lawyer. It is discouraging to hear such talk, but it is everywhere. I liked a local editorial cartoon that showed a patient in the OR about to have an operation. One of the figures in scrubs was putting his gloves on and telling the guy, “We regret to inform you that there aren’t any doctors left to operate on you, but rest assured that we have some of the best lawyers around filling in for them!”

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I have another big neurobiology exam behind me now. They are kind of like the anatomy exams. A lot of dense material, with a new language to learn, and they both give you the uncomfortable feeling that you just don’t have it all quite straight in your head no matter how much you study. We took the exam yesterday and I spent most of the week before and all weekend preparing. This class has me obsessing like anatomy did also. I even dream about the stuff. I have never had any problems sleeping before, but this course has me tossing and turning in bed at night. Even though I am quite sleepy, I’m unable to let it escape my mind long enough to nod off. The course is divided into three blocks and each exam is worth 30% of our final grade with the NBME board exam counting for the other 10%. Because each exam carries such a large weight I get more stressed over them than say physiology. In physiology we have nine unit exams plus a mid-term plus a final plus the board. Each unit exam ends up only counting for about 4-5% of our grade, so there is not nearly the pressure. In fact I have a GI exam in physiology this Friday and it almost seems like an easy week. Keys were posted after the neuro exam for both the practical and the written exam. I did just fine on the written but not so hot on the practical. I am not sure of the actual score on the practical, because I can never remember what I put down for each question. I might know that I had put down the right medial geniculate nucleus for one of my answers, but I don’t know if it was on number 32 or not. However I saw enough answers that I did not have anywhere on my answer sheet that I know that once again I have failed to beat my written component with a practical exam. We have had nine exams this year that had a practical portion, and I am 9 for 9. The format for this exam was a little different. We took the practical in the main lecture hall rather than the laboratory, and the exam items were slides shown on the screen. A professor would point to an area on the slide and ask us to either identify the area or describe what deficits a patient with a lesion in that area would experience. The images were actual stained brain cross-section specimens or MRIs or even drawings in some cases. We would have about one minute for each question. When a new image would go up, I would start thinking, “OK, that is a cross-section of the medulla. I can tell from the inferior olive that I am near the rostral portion. OK, what cranial nerve nuclei should I expect to find at this level? Would those be located medially or laterally?” Just as I would be about to hone in on an answer, my time would be up and I would have to frantically scribble down a possible answer, while never feeling really good about it. I felt like my problem was that I knew a lot of stuff and could think it out, but I hadn’t “memorized” the pictures in terms of seeing an image, immediately recognizing it and knowing where every tagged item in our atlas was. Oh well, only one more of these gut-wrenching tests this year.

Physiology is winding down with a whimper. Our GI exam is Friday, and then we just have two units on the nervous system. I have heard from the M2s that after having almost completed the full-blown neuro course, the material in physiology will seem like “Neuro for Dummies.” I think the class average for last year’s physiology nervous system exams were in the mid 90s. We do have a comprehensive final in that course which will require a good bit of review however.

Psychiatry is likewise just playing out the string. Most of the rest of the course is focusing on teaching us interviewing skills. We have divided the class up into groups of ten and each Wednesday we meet at the VA hospital, which is next door to University Hospital. These group sessions represent our first contact with real patients. These are psychiatric patients who are not necessarily veterans. I find it a little bit strange that our school uses this venue to begin teaching us about the patient interview. I know a lot of schools hire volunteer “actors” to present with certain stories and it is up to the students to try to figure out what role they are playing. Other schools use real patients but not generally psychiatric patients. I am not quite sure of the rationale, because it seems to me that we are “learning” in a more difficult venue for quality interviews than you would normally expect. My group’s first session was last Wednesday. We all trekked over to the VA together. We had been warned to not take our book bags as security is pretty tight and it would take quite awhile to run a hundred book bags through the X-ray machine. Right away, I knew it would be a different world. It turns out that just a few years ago, a disturbed patient came in with a gun and shot a doctor. Since then they have beefed up security and entering the hospital is a lot like to trying to get on a flight at Dulles International. A female psychiatrist and a female psychologist, who specializes in cognitive function testing, lead our group. They very briefly went over some interviewing techniques and then brought in our first patient. For this guy the psychiatrist conducted the interview so we could observe first hand, and then we got to ask questions. I would like to tell you a little about the guy, a young black male who had been admitted a few days previously for some psychotic episodes. However I have been made a little paranoid about discussing cases due to patient confidentiality concerns. We have been told that it is OK to discuss patients with colleagues but that we shouldn’t talk to family or friends or even to other doctors while we are in public places like the elevator. I understand the concern and the rights of confidentiality but I am kind of confused about the level of generality that can be used to tell about the experience. I notice that all of the writers on this site and in fact students everywhere talk about cases they have seen. Often specific symptoms and diseases are discussed and certain vital stats. Obviously names are not used, but it is certainly possible that someone who knows the patient could recognize them from a description given. I’d like to hear some of the other writer’s thoughts on this issue. Is it OK to say you saw a person with such-and-such diagnosis? What about revealing stuff like age, gender, and race? When does it quit being a matter of discussing things in an educational manner and begin to infringe on someone’s privacy? I don’t know. When we meet again tomorrow we will begin taking turns conducting the interviews ourselves. I am hoping to jump out and be one of the first in my group to go. I’ll report on that in my next entry.

To follow-up on the Question-of-the-Day for last week:
Which of the following occurs during exercise at aerobic levels?

The correct response (or at least what the professor was looking for) was:
3) Normal alveolar-arterial partial pressure of oxygen gradient

I answered: 2) Increased alveolar partial pressure of oxygen as did 42% of the respondents. It is true that even during exercise, arterial partial pressures of oxygen normally do not increase much. However oxygen consumption is up, so I would reason that the oxygen partial pressure on the venous side is down. Of course the systemic venous blood is the pulmonary arterial blood. The lower partial pressure in the pulmonary arteries should lead to an increased pressure gradient in the alveoli. That was what I figured anyway. If you can explain what is wrong with that reasoning, post a comment.

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Today found everyone’s favorite physiology teacher / Survivor show applicant / movie-star-wannabe under siege from irate exam takers for Friday’s respiratory system test. I am sure poor Dr. Hester did not know what hit him after some of our more illustrious question challengers unloaded both barrels on him. It is all quite comical to watch the indignant proclamations of, “I’m going to get that point back!” I will admit that I found a few questions to be either poorly written or have more than one possible answer. Of course on multiple choice tests you are supposed to pick the BEST answer. Sometimes life is not black and white and you have to choose the most reasonable from a set of possible choices. I am including one particularly debated question as my Question of the Day. I will be interested in seeing which answer some of the readers find to be best.

I am now certified in Basic Life Support and am glad to have that over with. The instructor was pretty personable for our skills test. She gave me a brief interview to find out something about me and then gave me some make believe scenarios which tied in with my circumstances to test me on. The first case was that of a middle-aged man who passed out in the middle of Pearl Day festivities, a pretty plausible happening as Pearl Day is a town birthday party in my city held in late June in the City Park. It usually is about 90 degrees and 80% humidity for the day. I just hope I would be able to successfully transfer skills with a mannequin in a non-stress situation to a life or death situation in front of hundreds of onlookers.

We started a gastrointestinal system unit in physiology today. I think it will be good fodder for plenty of bathroom jokes from our not-too-serious professor. He started out his series of lectures with a “tour” through the digestive tract using images from a scoped patient. The final one was the anus, with a slide conveniently noting that this was the “internal view.” He suggested if we needed an external view that we could use a mirror later. Some of the more uptight students found his humor crude I’m afraid but for the still immature crowd like myself, he shows great promise as an entertaining lecturer.

In news from the home front, we had Manning into clinic this morning to discuss the results of his recent pH probe test. It came out “negative” which meant that no reflux episodes were noted, which simple observation had already told us. And amazingly enough he has had the problem almost completely resolve in the last three weeks. Hopefully he is over it, and we can return to some of our old feeding habits. We used to bolus feed him five times a day through his feeding tube and each one would last about 15 minutes. One of the lifestyle treatments for his reflux had been to put him on a pump feeding system, which spread his feedings out to an hour. That amounted to five hours a day. While he didn’t need to be constantly watched during these feedings, they did make it difficult for Angie to plan extended outings. Also Manning’s seizures have decreased both in frequency and intensity in recent weeks. He is only having 2-3 a day for the last month or so and he is noticeably more alert, vocal, and tonic. We are seeing his neurosurgeon Wednesday and are anxious to tell him about the recent improvements.

I am coaching my older girls 9-10 year old softball team. We started practice last week and it is a lot of fun. Right now I only have tow practices a week and the season does not start until the week school gets out so it does not take too much time away from studies. I’ve got to have some outlet for my spring fever and spending a few hours outside in the evening is just the ticket.

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It has been a long week so far. Normally we don’t begin on Monday mornings until 10:00, which is outstanding, but this week was my turn for CPR skills review. I had to report at 8:00 for a practice session on the mannequins and I have an individual skills exam on Friday that I have to complete to get my certification in Basic Life Support. One of the requirements of this course is that we buy a “pocket mask” to use when ventilating a person in need of resuscitation. They cost an outrageous $24 in our bookstore. I can’t see dropping that kind of cash for something I will use for a 20-minute test once in my life. I sure won’t be carrying it around with me in the future as I await a real-world situation to put my CPR skills to the test. If I see someone in need, I am sure I will be able to suck it up and do the direct mouth-to-mouth resuscitation that has sufficed for years. For the test I am hoping to borrow someone else’s mask.

Monday in Psychiatry we had another case study. We met a patient who suffered from bipolar disorder and he openly discussed it with us. This guy was a super high-achiever. Athlete, scholar, big-time corporate lawyer by his mid-thirties and money out the wazoo. Unfortuantely, he managed to completely screw his life up before he was diagnosed at age 51. Now in his sixties he told about being involuntarily hospitalized 7 times in the last decade. Once, in a pair of handcuffs. While the true depressive and manic phases of bipolar disorder last for days or weeks at a time, I could see pretty impressive mood shifts in this man right in front of my eyes as he spoke. He talked at 90-miles-an-hour and jumped from thought to thought like an old man doing a triple jump in a checkers game. He would have a gleam in his eye while he told us about totaling his Porsche and the next minute would be near tears when he told how badly his actions had hurt his family. I am very impressed at the courage he and our previous anxiety disorder patient showed in standing up before our class of 100 plus and spelling out there psychiatric illnesses. This particular case was perhaps the most powerful thing I have witnessed so far this year. I was pretty moved by this man in some way that I don’t yet really understand. He was so smart and eloquent and yet so lonely and defeated. He obviously has studied his disorder in great detail and understands it well. He brought up noted artists and writers who were probably bipolar. Vincent Van Gogh, Ernest Hemingway, and Virginia Woolf all had periods of incredible creative output and eventually committed suicide. Quite common in bipolar disorder. In fact during a hypomanic an individual can get a lot of things done and be wildly productive. It is sad and ironic that the condition which can help to produce so much can be so destructive to the individual. I don’t think I want to go into psychiatry but I have to admit that this stuff does fascinate me.

Monday and Wednesday are the ling days in our spring schedule. We are in lecture or neuro lab until 4:00 with only an hour for lunch. Tuesday afternoon are open however and I was excited about going to neurology grand rounds this week. The neurology department had posted an open invitation on our lecture hall door a few weeks ago to any students who were interested in attending. The format is a conference room session wherein the neurology residents present their patients to the department chief who then helps with differential diagnosis. I had gone home after morning lectures and started getting ready to return to the hospital for the 4:00 rounds. Following the instructions on the invite I put on my white coat, for only the second time. My nine going on nineteen-year-old daughter saw me and said, “Aw, Daddy is growing up! Getting to wear his doctor coat!” Even with her patronizing, I was still excited about going. Unfortunately I sat in the conference room alone for 30 minutes studying my neuro atlas before a real doctor came in and told me the grand rounds had been cancelled this week. “All dressed up and nowhere to go!” she told me sympathetically. I guess I looked kind of pitiful.

I had class notes today for our 9:00 AM physiology lecture. Because our test is on Friday I have to have the notes distributed by 5:00 PM tomorrow instead of the normal 48 hours allowed. I have spent the evening preparing those instead of studying, but at least I should not miss any of the exam questions from my lecture. Tomorrow I will spend all of the non-lecture hours cramming for our respiratory exam in physiology Friday morning. Once that is over, it will be nothing but neuro for a week. The next exam is on the sensory pathways. Pretty neat stuff.

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It is April and a young med student’s fancy turns to … baseball! Will the game be a soothing balm, the comforting presence of a friend who disappeared for five long months and is now back to guide me through the remainder of first year with a new fire and determination? Or will the great game’s lure be a weight around my neck and drag me down into complacent mediocrity for the last seven weeks as I stay up blurry eyed every night to catch Barry Bond’s last at bat out on the left coast? Hmm. I better turn the TV off now and start reading about the somatosensory system.

Monday was Opening Day of baseball season, always a great holiday in my life. I played hooky in the seventh grade to watch a Reds v Braves opener back in 1980 and have pretty much taken every Opening Day off in some sort or other since then. This was the first day of the entire first year of medical school that I blew a day off so I didn’t feel too guilty. The days festivities included some one-on-one hoops at a fellow fans house, a viewing of the movie Major League, followed by ESPN’s coverage of the Braves v Phillies and the Mets v Pirates. Of course there were smoked sausage dogs, nachos and ice cream sandwiches involved also. It is important to capture the ambience of the ballpark.

I have had a very difficult time getting back into the study grind since last Wednesday’s first big Neuro exam. I barely spent any time on this week’s endocrinology exam in physiology. I just could not get real interested in it as we have covered the material in both biochem and histology. I went into the test as poorly prepared as I had been for any test this year but still managed to scrape out a passing score. The next unit on respiration promises to be more up my alley.

We also had a psychiatry mid-term exam this week and it turned out to be uglier than I expected. There was even a question about what enzyme catalyzes the final pathway in the synthesis of some neurotransmitter! Sheesh, I though I was through with biochem! I figured it would be more along the lines of giving me a guy’s symptoms and asking what the diagnosis is. That’s always easy – answer (b) : crazy!

I had a nice chat with the director of the Neurobiology course this week. Dr. Haines is the head of the anatomy department and an excellent teacher. He asked about my little boy. I was not even aware that he knew about Manning. He shared with me the fact that he too had a special needs son who is now 26 years old and was able to empathize with my situation. I really appreciated his interest. I asked him how he knew about Manning and he told me about reading an article that was written on Manning back in the fall in our local paper. It was a real nice article and I have had numerous people both from school and around town that have come up to me and mentioned having read it. I have posted a link to it here if you would like to check it out. Dr. Haines is also currently collaborating on some type of project with Manning’s neurosurgeon, Dr. Lancon. They are both incredibly smart men, and I am pleased to know that there are people like them in the world working hard to understand that most mysterious of biological innovations – the nervous system.

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Sorry for going AWOL over the last two weeks … I have had a lot going on. Let’s try to catch up on things.

First of all, I am a little bummed on Neuro. We had our first block exam on Wednesday. We were allowed to keep our written tests and a key was posted afterward, so I was able to check my score. I have myself down for an 86, which I am not thrilled about but can live with. I missed 9 out of 65 questions but I should have got at least three of those. However I am afraid I did much worse on the practical. They posted a key for that one too, but I can never remember what I answered well enough to check that one. I had spent a lot of time with the “brain buckets”. These are the specimens that were removed from our cadavers back in Gross. I think I did well on most of the questions that came from actual tissue specimens, but out of the almost 50 items on the practical, probably a third were photos of MRIs and stained slices. I guess I didn’t look at the atlas hard enough for the slices, because a lot of those photos looked like abstract art to me rather than portions of the human brain.

The really frustrating thing to me is that this is the course I really wanted to excel in. Neurology is really what brought me to medical school because of Manning’s problems. How will I ever help him if I don’t master this stuff? There are a ton of doctors out there who did better on this test than I did, and they haven’t been able to “fix” Manning. What makes me think I will be able to? Another disturbing trend – this is the third course we have had with a practical exam component to it. Without exception I perform much better on the written than on the practical. I am beginning to think I am lacking in observation skills and those are what physicians really need. It won’t do me much good if I have all the book learning in the world, but can’t recognize what I’m seeing on the patient.

Another thing keeping me busy this week was a visit from my mother who lives in New Mexico. She is a high school Spanish teacher there and was on spring break this week. I had not seen her since last summer. She usually visits more frequently, but had to have cataract surgery over her Christmas break and had to cancel travel plans. I tried to spend the time I wasn’t studying visiting with her, and that took my writing time away. Only so many hours in the day and all that!

We had a consult with a pediatric surgeon here in Jackson regarding Manning’s stomach reflux problems this week also. He ordered a 24 hour pH probe test. This involved a tube up Manning’s nose and into the pharynx where pH levels were measured on a portable device. Naturally he went the entire 24 hours without a reflux episode. He has in fact not had one in the last two-and-a-half days, so we are hoping that things are improving in that area. We haven’t heard what the results showed yet. Also the nurse from neurosurgery has told me that he has been tentatively put on the surgery schedule for the Vagus nerve stimulator device implant in June.

Thursday we had the highlight of the Physiology labs for the year. Most of these “lab” sessions are actually done on PCs and involve manipulating the treatment of a computer-generated patient. This one however was the much talked about and anticipated “dog lab.” The class is divided up into groups of 16 and the groups take turns over several weeks participating in the lab. It consists of doing some surgery on an anesthetized dog and then doing some experiments to learn about blood pressure and heart rate. We went into a small operating room in the Clinical Sciences building, and each sub-group of four students got their own dog. The animals had already been anesthetized and were tied down to the tables. These animals are older dogs that are on their last legs and are going to be put to sleep anyway. There are also vet techs on hand that monitor the anesthesia and insure the animals are being treated humanely. We made incisions in the groin to expose both femoral arteries. On one side we ran a catheter up into the left ventricle of the heart and on the other side placed on just a few inches into the femoral artery. These lines had transducers on them to monitor blood pressure. We also got a line in the femoral vein for drug injections. We then exposed the common carotid artery and vagus nerve on each side in the neck. Once we had completed our surgeries, the experiments begun. We observed the effects on heart rate and blood pressure for epinephrine, norepinephrine, acetylcholine, and angiotensin II. We had studied the effects of these neurotransmitters and hormones in class, but it sure does reinforce things in your mind when you see it happen before your eyes. We also temporarily occluded the carotids and then severed the vagus nerves to see what the response would be. After all of this we got down to the really cool stuff.

When our lab instructor, a research PhD asked who wanted to open the thorax I quickly volunteered for our group. I opened our poor hound dog up between the fourth and fifth ribs and after spreading the ribs open, we were able to observe the pretty pink lungs expanding and inflating with each breath. You might recall from my gross anatomy entries that for some reason that lung tissue fascinates me. Then we pulled the heart out from underneath and actually held the pumping mass in our hands. A very powerful feeling. The plan had been to induce a ventricular fibrillation with an electrical stimulus, but our dog spontaneously went into fibrillation. Who could blame it after all we had put it through? In fibrillation the heart has no rhythm and different regions are contracting spasmodically with no concert of effort. It has been describes as the “bag of worms” and that is exactly what it looked like, a little bag, jam-packed full of wriggling night crawlers. It was pretty wild. My lab partner, Alison got to use the defibrillation paddles to restore a normal rhythm and saved the dog’s life (albeit extremely temporarily.) Alison is a true warrior on this kind of stuff. She made all the rest of us look like sissies with our latex gloves on. She preferred the bare handed technique of surgical procedures and by the end of the lab had blood halfway up to her elbows on both arms. She has worked in research labs for the last couple of years and has plenty of experience with animals. Anybody who wanted could hang around and practice suturing, intubations and just about any other procedure they could think of. When we were through the animals were destroyed, but their last day was spent giving us a wonderful educational opportunity.

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Monday morning after spring break. It is good to get back into my routine. I had a fun time, but I am ready to get back into the books and finish this first year.

I meant to post a couple of times over the break but I got the spring cleaning bug and took it out on my PC. I like to reformat my hard drive every now and then and reinstall all my software to get a fresh machine. Nothing speeds up the old dog like a nice clean Windows registry. My current PC is a Dell notebook with one bay, which can swap between a CD-ROM and a floppy module. I had never attempted an operating system reinstall on this machine and it turned into a royal headache. It took me about three days to get things back into shape. I had a lot of trouble getting my USB devices reinstalled and my DSL internet connection didn’t want to stabilize. Hopefully all is well now, and I learned a lot about my computer. It is frustrating how difficult these things have become. I remember being able to completely reformat the drive and get everything back up on my first PC in an hour’s time. I guess it’s the price I pay for my techie nerd OCD habits.

Also I spent a large part of spring break recovering from some kind of respiratory illness. I began feeling bad the Thursday before we got out. My head was full of congestion and I had a terrible pain in my ear due to pressure buildup. I was up most of the night and stumbled into my 9:00 AM Physiology exam not feeling to spiffy. That was the only class we had Friday, so I was able to go by Student Health services and find out that they did not have a doctor in. Luckily I was able to get the Dean of Academic Affairs who is also an Infectious Disease specialist to examine me. She put me on Augmentin and I made the mistake of taking my first dose before heading home. I hadn’t eaten anything since the night before and by the time I drove home, I was sick as a dog. I managed to eat half a sandwich before going to bed for the rest of the afternoon, and by Friday night felt much better. My ear finally quit aching but unfortunately it felt like I had cotton stuffed in it and I couldn’t hear anything on that side. It still has not cleared and I feel like my head is inside a drum. Then later in the week I got a bad case of conjunctivitis that lingered for a couple of days.

It was not all pain and suffering though. I had a good time at home with the family. My oldest girls were on spring break also, and we hit softballs, shot a lot of baskets, saw Ice Age and generally had a great time.

We started a unit on Endocrinology in Physiology today. Another new professor to adjust to and get a feel for his style of lecture and more importantly examinations. We also had a real good lecturer in Psychiatry today who talked about cognitive disorders in general and Alzheimer’s Disease specifically. I had no idea how much progress is currently being made in this area. Apparently there is a vaccine in development that could soon be used to treat this devastating illness. Rats have been bred that develop Alzheimer’s at 16 weeks of age. When injected with the vaccine at birth they never develop Alzheimer’s and if they are vaccinated at 8 weeks they have much less severe cases. Pretty cool stuff.

My next big hurdle is the first Neurobiology exam a week from Wednesday. This is one of those courses where we only have a few exams so it is important not to blow one of them. This one will be 30% of our course grade. I will be hitting it hard for the next 10 days.

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I am trying to maintain some study momentum this week heading into Spring Break. It will be my first spring break since 1989 and I can’t wait!

This week in Psychiatry we are studying psychotic disorders such as schizophrenia. This is a disease that really sort of gives me the willies. It just seems so eerie to think that problems in the nervous system can manifest themselves in such bizarre ways. Even though it seems laughable in today’s more enlightened times, it is easy for me to understand how ancient cultures could attribute mental disorders to supernatural causes such as demon possession. I mean what else could you have thought when someone was seeing and hearing voices that no one else did?

We saw some video taped interviews with some patients that exhibited symptoms. One guy, who was a handsome young black man, was convinced that he had been horribly disfigured by surgery. He would furrow his brow and tell the doctor that all of the wrinkle marks across his forehead were the scars from where his face had been taken off and replaced. He was also convinced that both of his hands had been surgically removed and reattached.
Then there was also a video that tried to put you in the shoes of a delusional schizophrenic and show you what he was experiencing. This was a guy who, when he was not having a psychotic episode, could look back and methodically analyze and describe his experience. He related a time when voices in his head convinced him to go up on his roof and jump off. While he was describing this, the video put you in his head and you could hear the voices and see what he perceived. It was as scary as any horror movie to me! Of course many of the interviews would elicit laughs from the class, and I too would find them amusing. But I think somewhere down deep, the humor is just our way of dealing with something pretty terrifying – the idea that sometimes, things go terribly wrong with the real substance of what makes you “you.”

In neurobiology we are learning the anatomy of the central nervous system. I came into this course thinking about how much of the brain’s function is still a mystery but am finding out that even if that is the case there is a HUGE amount of stuff that we do know, and they expect me to learn it all!

In kind of a tie-in to our neuro studies, we are looking into having an implant called a Vagus Nerve Stimulator put in Manning. This is a device that is similar to a pacemaker. You implant it on the chest wall, and then a wire leads up into the neck and wraps around cranial nerve X – the Vagus nerve. The implant is programmed to deliver small electrical stimuli every 20 minutes or so. In some patients this has proven to reduce seizure activity through some still mysterious mechanism. You can tinker with the timing of the shocks with a computer and magnet tool. You can even pass a magnetic device over the implant at the onset of a seizure and sometimes abort the seizure. Hopefully we will know more about this in a week or so.

Now if I can just keep my nose to the grindstone for another 72 hours or so …

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Today was Primary Care Day at UMC. This is an annual event in which the M1 class is exposed to some of the day-to-day experiences of some of the clinics at the University. We met at 8:00 AM for breakfast at the Jackson Medical Mall which is an off-campus clinic site. For the first part of the morning we had a physician and a resident from Pediatrics, Internal Medicine, Family Medicine and OB-Gyn speak to us about their area of care. The class was then split into four groups and we rotated through each of the four clinical areas. We had been told to wear our white coats, so I assumed we would be getting a little patient contact, but it was a demonstration type of deal only.

In Pediatrics, they had mannequins of infants and children set up for us to practice intubation on. I have never done one of these, but was able to place the tube pretty quickly on the dummies. Unfortunately, I’m sure it’s a lot more difficult when you have a real life child and you have to worry about squirming, breaking of teeth, etc. In the OB-Gyn clinic we saw a doctor demonstrate Pap smear techniques on a model and heard about the kinds of things done on a daily basis. Family medicine had a little fair set up with a lot of demos. There was a breast tissue biopsy slide under a microscope, a model colon with a scope you could use to check for polyps, a body fat composition computer, and a sports medicine display. The Internal Medicine doctors presented a case study on a 35 year-old woman who presented with fatigue and shortness of breath. Through her history and testing we determined that mitral valve stenosis was a likely diagnosis. They then demonstrated a heart echo machine on one of our classmates.

The rotations were followed up with a nice lunch and the whole thing was over by 1:00. I was disappointed that we weren’t dealing with real patients as I had mistakenly anticipated, but it was a fund day and nice to have no classes.

I forgot to mention a good experience Monday night. The Pediatrics department sponsored a party for the M1 and M2 class at a downtown eatery that specializes in homemade pizzas. Spouses were invited also, so Angie and I went and had a great time. The speaker was Dr. Sorey, a pediatrician who gave a light-hearted talk on how to save face at family reunions when you eventually became a doctor. He guaranteed us that relatives would challenge our diagnostical acumen by presenting all sorts of rashes and lesions to us in the food line and want to know what they were. He then took us through a series of photos demonstrating some of the stuff we would likely be challenged on one day. Despite the levity, he did say one thing that really resonated with Angie and me. He said that as a pediatrician he was not always able to fix the children. Sometimes he had heartbreaking cases where he could not cure the patient but he could do whatever was in his power to make their life and that of their families better.

Angie and I were taking Manning to Huntsville, Alabama regularly a couple of years ago to see a doctor who we though a lot of. Dr. Bebin always was so kind to us and so reassuring. We were getting a lot of advice from well-meaning friends and relatives, telling us we should try this or go to that place, and Angie was afraid that she was not doing everything she could for Manning. Sometimes when you are not getting results, it is easy to feel that way, despite the fact that you are getting the best care possible. I asked Dr. Bebin if she felt we were doing the right things and sensing Angie’s distress, she exclaimed, “you’re a WONDERFUL mother. Manning couldn’t possibly have someone better to take care of him, and you have done everything you can do.” And she said it in a way that made you know she MEANT it. It was a poignant moment and as we drove the 350 miles home, we talked about why we continued to travel so far for what amounted to routine check-ups. And the answer we came up with was, “because Dr. Bebin makes us feel better.”

That is exactly the thing that Dr. Sorey was talking about. That is the kind of doctor I want to be.