Adventures in Child Neurology

>

After an incredible weekend of rest, warmth, sunshine and no studying, things have gotten back to normal. As if to emphasize the need to get back to the grind, our early tease of spring has yielded to a cold front. It is supposed to drop below 20˚ tonight which would be a record low for the date. Oh well, they keep it warm in the library.

In class we have started the renal unit in physiology. Body water compartments, fluid replacement, nephron function and the like. I am finding it to be a lot more interesting that I would have thought.

Neuro started yesterday, and we had our first lab. We examined the brain specimens that we had removed from our cadavers back in the fall. Each group was assigned, a whole brain, another brain split into hemispheres, and a loose spinal cord. The smells took me back to those days of gross lab which seems like years ago.

Our new psychiatry unit also began this week. It kicked off oddly enough with a neuroanatomy lecture. This lecture supplied my favorite quote from med school yet. Back in 1848, a man named Phineas Gage had an accident in which an explosion drove a tamping iron through his brain. He lived through the incident and neurologists of the time were able to learn quite a bit about the function of the frontal lobe of the brain from the weird personality changes that Gage underwent. There is a lot of cool information to be found about this case on the web. Anyway, the quote I liked was our professor’s description of the injury as a “profound and stunning insult.” You’ve just got to love the way these PhDs put things sometimes.

Monday, we had a mandatory CPR training course. We watched an American Heart Association training video and have to take a written exam on it next week. Then we divide into small groups and take turns over the remainder of the year going for personal hands on training with the mannequins. I have been exposed to some of this stuff before but have never been certified or anything. I am glad to be getting this stuff. It would be awfully embarrassing to be in a situation where somebody needed emergency assistance, and after being identified as a medical student I had to admit I didn’t know how to give CPR. I could probably fake my way through it, but now I think I will feel a little more confident.

My schedule for the remainder of first year consists of 8 hours of physiology lecture, 6 hours of neuro lecture, 3 hours of psych lecture and 4 to 6 hours of lab time per week.

Oh yeah, I’ve been meaning to give some anecdotes about two of my professors. One of the physiology guys (the same one who has worked with the cremaster muscle for two decades) is obsessed with getting on the Survivor TV program. He has applied for every incarnation of the show and while giving his series of lectures was preparing a video to send in for the latest version which will be taped this summer. Apparently you have to put together a little video about yourself. He had his assistant tape him giving a lecture, and then pan the students. We all feigned unconsciousness at his request. I guess he is going for the humor angle. Or maybe he figures a nerd professor is one of the personas the show needs.

Another PhD in the Anatomy department is very big into dog shows. He has several prize winners apparently and is a regular on some of the dog shows that ESPN2 airs late at night when there are no college basketball games to televise. I have not ever actually watched one of these, but have heard about it on good authority.

>

We are almost through with our exam block. We took our Psychiatry final today and have a study day tomorrow for our Physiology mid-term on Friday. I have been pretty hard core with the books for the last ten days, and it feels good to have a chance to come up for air. Angie and I are going out to lunch at a favorite place Friday when I get through. My girls have a soccer tournament Saturday and I’m hoping our current beautiful weather will hold through the weekend so I can bask in the sun while watching the games. Today was an awesome short sleeve day with brilliant blue skies and temps near 70.

I am also gearing up for our final quarter of first year. We start neuroanatomy on Monday. I went through the mixed emotion experience of buying the books for the course today. I love getting new books, but I hate the steep prices. I dropped a Ben Franklin for the main textbook, an atlas, and a lab guide. Though I should be studying for Friday’s test, my slightly OCD side made me browse through the new material. I think it will be a real tough course, but I’m interested in the subject so hopefully I’ll stay motivated. Manning’s neurological problems are what pushed me toward med school in the first place, so here is my first real chance to learn exactly what is wrong with my little man.
Monday morning we have to be at school at 8:00 AM for a CPR training course. After that, though we don’t start on Mondays until 10:00 for the rest of the year! It will be nice to have that extra lounging time around the house to start the week. Also, we are finished at 11:00 on Fridays the rest of the year! It promises to be a pretty enjoyable spring. We pick up a second Psychiatry course Monday also. I think it is more geared toward disorders than the course we just finished was. We will also be getting our first patient contact in this class, as we interview patients at the VA hospital. It will be the first chance we have had to wear our white coats. Along with psych and neuro, we will also continue with physiology until the end of first year on May 25th.

In other developments, we contacted the surgeon who did Manning’s gastrostomy and fundiplication back in 1999 to get his take on Manning’s current reflux problems. Dr Georgeson, who practices in Birmingham, Alabama, about three hours from here, wanted to see Manning. I could not get away with exams going on, so Angie’s mother took off from work to go with Angie and Manning. Of course 9 month old McKenzie was in tow, so it was great for Angie to have the help. Dr. Georgeson believes Manning’s reflux is stemming from neurological causes rather than gastro ones. He gave us some good ideas to consider and I am trying to meet with Manning’s local neurologist to discuss the findings.

>

Sometimes you just have to set priorities. No more book reading for physiology class this week. I had been really good about keeping up with the readings for this class, but the first two exams have shown me once again that WHAT YOU NEED TO KNOW IS IN THE HANDOUTS. Of course, the background reading does help to cement the ideas and clear up concepts, but with a histology exam looming Monday that will be one-fourth of my grade for the course, I have got to devote the week to that. The physiology exam on Friday will only be worth about 5% of our grade for that course. Next week is a big exam block, with the aforementioned histo exam on Monday, the National Board Exam in histology on Tuesday, our psychiatry final on Wednesday, and a physiology mid-term exam on Friday. I can’t wait to have the histology class over and done with. We will really be on the downhill stretch when next week is complete.

A lot of stuff is going on at home to keep my mind on other matters. Manning saw the gastroenterologist last week Of course he did not have one of his reflux episodes while having the upper GI done. She prescribed some erythromycin to help clear his stomach out to see if that would help any. She wants to try that for about two weeks but we have not seen any improvement so far. She said if he didn’t get any relief from that, she would refer us to a surgeon to explore a new fundiplication. Manning had the first one done at the Children’s Hospital in Birmingham, Alabama. At the time there was not a surgeon locally who felt comfortable doing the procedure on such a young child. There is one here now, but I want to call Manning’s prior surgeon first thing tomorrow morning just to get his take on our situation. I will try to talk to their office before classes start for me at 9:00 A.M. Angie will be available but she really feels more comfortable with me explaining the situation and listening to what the doctors have to say.

Beyond that, our 8 month old McKenzie is requiring the normal full-time attention that babies require and our pre-teen daughters are both undergoing dental work. I have health insurance for the family through a group policy the med school offers the students, but it does not include dental coverage. What a blessing to have my in-laws taking care of the girls teeth! (Thanks Grandma and Grandpa!) Both of them have a narrow palate and are having appliances installed which will gradually spread their palate and allow room for their emerging permanent teeth. My nine-year-old, Macey, had hers installed today and she was a little sore. The ten-year-old, Morgan, had to have some remaining deciduous teeth pulled to hasten the arrival of her permanents to use as anchors for the appliance. So of course studies were interrupted tonight to make a Sonic milkshake run for them.

I’ve got the whole family bedded down now and will try to plow through some histology notes before sleep overtakes me.

>

We’re in the middle of a pretty quiet two week stretch leading up to the end of our winter quarter. Then we have a barrage of exams lasting a week. The good thing is we have no classes that week. Histology will be over then and we will be on the downhill stretch for first year. Wow. It has flown by. I was thinking about how much I have learned this year and how things are really beginning to take. The image I come up with is one in which my knowledge base is a long downhill tunnel. At the beginning of the year I was getting all kinds of information thrown down the tunnel. I would get some of it to stick to the walls as it went down. Hopefully it would stay on the walls and not ooze completely to the end of the tunnel and fall out before the exam. Without me even realizing it though, some of these facts and concepts firmly attached somewhere along my information tunnel. Now I have several ledges and crevices built up where more and more stuff can accumulate. Some of the things we studied in Anatomy and Biochemistry are being repeated in Histology and Physiology, and what once seemed arcane and random now seems relevant and familiar. When somebody talks about angiotensin converting enzymes, I actually know what they are talking about now. It is a wonderful feeling to see a lot of things coming together and realizing that, yes I really can do this, and I will be a doctor one day. Don’t get me wrong, I still have to have my Stedman’s Medical Dictionary handy to read Ron’s diary, but I’m getting there!

One really cool thing we saw in Physiology was a video of some research Dr. Hester is doing on the circulatory system. He takes hamsters and under anesthesia splays their cremaster muscle (If you’re not sure where this muscle is, look it up – it may be painful if you’re male!) out under a microscope. You can actually see the blood coursing through arterioles, venules and the capillary beds. In the capillaries there is room for only one red blood cell at a time and there are junctions where red cells will wait for a gap in the main line to jump into. It looks like cars merging on to the interstate. The research being done is on hypertension and such. A drop of adenosine can be placed on the muscle and almost immediately the vessels will dilate substantially. Dr. Hester told us that back in 1982 he first saw this type of research being done and said to himself, “That’s what I want to do!” And he’s been doing it ever since. I didn’t have the nerve to ask the main question on my mind – “Don’t you ever get finished?” By the way, I think Cremasters would make a killer name for a kids soccer team.

One other thing going on today; my little boy Manning has been having a lot of reflux problems. He is fed via a gastrostomy tube and has had a fundiplication. (A portion of the fundus of the stomach is wrapped around the base of the esophagus creating an artificial valve to keep stomach contents in.) We had a barium test done today, and of course he did not exhibit any symptoms for the radiologists. We see his gastroenterologist tomorrow for a follow-up. We are thinking that he needs a new surgery to redo his fundiplication. The original surgery was done 3 years ago, and he never had any problem with reflux until his hemispherectomy complications last fall. I think he has probably just grown such, that the existing wrap has loosened up too much.

>

An absolutely beautiful weekend was squandered in the library. I crammed all of the Histology I could in for our exam today and much of it took I think. So much of our studying comes down to cramming and then purging, but I can’t help but think that at least a few major facts will stay with me.
One of the things that has surprised me about medical school, is the challenging of test items by the students. It seems to me that in college, the professors never threw any questions out or accepted alternative answers after the original grading. Yet here in medical school, it is almost routine for us to get a question or two tossed out on each exam. It seems that there is a core group of students who want to argue with the instructors over every question they miss. I kind of get irritated with them. I have missed some items that I thought were ambiguous or unclear. I remember a segmented bronchus on gross anatomy practical exam that I am positive was mistagged But I figure that life is not always fair and just suck it up and take it like a man. But no! We’ve got some students who are all over themselves to argue for points on every single question they miss. And of course its always the ones who have made an A anyway. They make a 94 but will not stop whining until they get a point back to get them to 95. I mean I can see maybe if you need a question to pass a test, but come on! Some classmates even approach test-taking with this in mind. Instead of looking for the best possible answer on a multiple choice if they are unsure, they talk about picking the one that they can argue for the best. I guess this is to be expected when you are dealing with a core group of extremely motivated and competitive people.

Looking at it as an observer, I can see two sides. On one hand, it would seem that a poor job is done in writing examinations if questions have to be tossed out. I mean these are professionals in their chosen fields and they should know the material well enough to write fair questions. On the other hand, the material is quite complex and sometimes the students have read the textbook more thoroughly than the PhD who had all of this stuff 20-30 years ago and is more worried about his ongoing bacterial DNA gene splicing research than reading the 13th edition of the basic science textbook of his discipline. I think some of the professors give in too easily on this stuff. Multiple choice exams always say to select the BEST answer. Sometimes more than one answer is POSSIBLE but one is clearly better than the other. Oh well, I have benefited from the griping of others but I just don’t think an extra point here and there is going to matter much four years from now.

Oh, our school Physiology department just updated their website and yours truly is featured sitting in class looking stumped. Since the site here currently doesn’t have photo upload capabilities, you can check it out here:
http://phys-main.umsmed.edu/TEACHING/medical/Overview.HTM
I am the guy holding the pen at the bottom.

>

Is there any part of the body that has been written about, romanticized, and imbued with such symbolism as the heart? We started studying the heart in Physiology today. I wonder how the heart came to be equated with the center of emotions? Poets have written about it as a symbol of love forever it seems. The history is powerful, because even today, when we know that all of the things once attributed to the heart, actually reside in the brain, we still use the heart as a metaphor for love, courage, and kindness. One of the helpful things about Gross Anatomy is the permanent image it stamped on my mind for the internal body structures. I can still see my cadaver and the placement of his heart clearly. We actually took the heart out and dissected it thoroughly back in the fall (which seems almost an eternity ago!) and knowing the structure makes learning the function so much easier. As part of today’s lab session we had to get an EKG done on ourselves. The guys were segregated from the girls who for some reason did not want to bare their chests in front of us. Several of the guys were not to eager to go first, but when I visually ascertained that I would not be the fattest slob in the group I jumped to the front. The leads didn’t stick to well to my hairy chest, but I managed to get a printout to prove that I had done the lab. We are just beginning to learn to read EKGs and will have a printout of our own heart’s rhythms as we study. Having finished up the lab early I was able to get some reading in the rest of the afternoon.

We have our second Histology exam coming up on Monday. This has been a great class so far. The instructors are great. Dr. Naftel who is the director for the course has been super. He goes the extra mile to help students learn the material. Every Saturday morning he voluntarily comes in to give us a review session for all of the laboratory work we were assigned for the week. He apparently comes in early and sets up a microscope with a TV viewer, and gets all of the slides in order. He then goes to the local Krispee Kreme doughnut store and picks up a gross of HOT doughnuts for us. (If you have never had fresh Krispee Kremes right out of the “river of grease” as I call it, you have not lived.) The review session starts at 10:00 and he patiently walks us through slide after slide pointing out things we need to know for our practical examinations. I have not had another professor who does so much on his own time as Dr. Naftil, and it is much appreciated.

Another cool thing about Histology is the number of great web sites available for study. For the first exam, I found it much more helpful to study a lot on the net at home (I LOVE my DSL line!) than to spend a lot of time in the lab looking at slides with my own microscope. I am hoping to get away with that strategy for this test also.

Yet another thing I like about this course, is the notes the professors write for us. In most of our classes, our note service writes up notes, but they still need to be supplemented with printouts of the lecture slides and textbook material. The Histology profs though, write up very detailed notes for each lecture and they pretty much contain all of the information we need to know for exams. They seem to be the only department that realizes that we medical students are so busy that we cannot possibly read all of the assigned textbook material, or at least read it all with full comprehension, given our time constraints. I try to read each lecture note three times and look at just the diagrams and illustrations in the text to cement the concepts.

The most important thing I have learned in Histology so far though, is something your Mom has probably preached for years – wear sunscreen! Melanoma is not a pretty thing.

>

We are now full swing into Physiology and it promises to be my favorite first year course. Our first unit covered material that we had already studied somewhat in Biochemistry and Histology so for once I didn’t feel too far behind all of the pre-med education path students. And I was really pleased when the graphs and equations showed up! I am more the quantitative type thinker and it look like this course will have plenty of that. We took our first test today and I almost aced it, missing just two out of 28 questions. It would sure be sweet to get just one perfect exam back this year. Oh well, the quest continues.

One of the crown jewels of the University of Mississippi Medical Center is Dr. Arthur Guyton. Dr. Guyton is a world renowned physiologist who has done ground breaking research on the cardiovascular system since the 1940s. He authored the textbook we use and I understand it is the most widely used Physiology textbook in the world. He has had to get around by crutches and wheelchair since the 40s due to the effects of polio which he contracted as a surgery resident. I saw the great man wheeling around the department the other day and it was inspiring to see someone who has had such an impact in the field of medicine. He has a real interesting story. You can read more about him at http://www.umc.edu/guyton/index.html

>

I love fresh starts. After a hectic week of exams immediately after the holiday break, a confluence of events has made my life seem new and full of promise again.

First of all, we finished biochemistry finally. This class had started on Day One of medical school and at times seemed that it would never end. I got more and more frustrated with it as time went on, because while I found the topics covered to be of great interest, I was getting lost in the details and all of those enzymes were running together in my head. I made an A on the first test of the year and spent the rest of the course watching my average plummet. To all those people who told me that it would not be a hindrance to have never had a biochem course in college … you lied! I didn’t really see the big picture until near the end of the course. The other big difference in my mood came with better weather. After a few weeks of near record cold temperatures and then rain, we have had beautiful weather for a week. But for the leafless trees, it has almost seemed like Spring. I know that more miserable winter weather lies ahead, but for now, I am enjoying the respite.

For the first time since the beginning of medical school, I feel like I am caught up with my studies. We finished our first unit in Histology and I did well on the first exam, so unlike Anatomy, I don’t feel like I am starting off in a hole that I have to dig myself out of. Physiology has just begun, and I am actually familiar with the material so far. There are even some equations to solve, which warms my math and physics loving heart. Psychiatry began last week also. It seems to be the closest thing to a sop course that we will have in medical school. The course is divided into two blocks with the first one covering some basic behavioral science. It is only 16 hours and 90% of the grade comes from the only exam in the course. The other 10% is to come from three unannounced quizzes. We had our first of those today, and apparently they are really only designed to encourage class attendance as it was trivially easy. My first 100 in med school!

I feel like my “adjustment period” for med school is over now. I know what to expect. I am really here, and I know that I belong. That might seem an odd sentiment for anyone reading who has gone straight from a pre-med program to medical school, but I am sure that those who have been out of the classroom for a decade or more will understand.

>

I have had several people wonder what the medical school experience was like for the rest of my family. I have been married 13 years and have four kids. The girls are Morgan, 10, Macey, 9, and McKenzie 7 months. My little boy is Manning and he is 4 and a half years old. Manning has had a severe seizure disorder since birth and has never been able to make much developmental progress due to daily seizures and abnormal brain waves. My wife Angie, is a saint among women. She provides him the constant care he requires as well as taking care of the rest of us. In response to several requests, she has done a couple of diary entries herself this weekend, and they are the two entries posted prior to this one. If you have been interested in her perspective, give them a look!

I am burned out. I just spent a marathon week of studying that was probably my most productive week of the year so far. We took our Biochem Final exam Friday and our first Histology exam today. We still have a National Board in Biochem on Thursday to get through, but then I will finally have a chance to catch my breath for a few days. Two whole weeks before our next exam!
We start two new classes this week, Psychiatry and Physiology. I have always kind of had a lurid fascination for the panorama of odd behaviors that people can exhibit, so I think I’ll find the Psych class pretty interesting. It is really amazing to me how physical phenomenon going on in the brain can manifest themselves through strange behavior. I don’t know much about Physiology but it seems like a real meat and potatoes type of course for a would be doctor. I guess I better get into it also.

Our oldest girls had their first basketball game in a local Youth league tonight. It is the first year for each of them to play in an organized league and we had a blast. I am sort of helping to coach so I got to sit on the bench. They play in a three-on-three half court league. We won 27-22 in a pretty well played game for 9 and 10 year olds. My oldest daughter scored four points and played good defense. Her little sister never saw a shot attempt she didn’t like and scored 12 or 14. I lost track. She apparently believes in my philosophy – you can’t get hot unless you shoot it.

It felt great to take a night off. It is only 10:00 PM and I’m headed for bed!

>

I am writing this about 8 and a half hours before my comprehensive final exam in biochemistry. I have reached that saturation point where I think anything else I memorize will bump something else out. I think I have already deleted some important brain cell contents like Carl Yastrzemski’s lifetime home run total. Yep. I just looked it up on http://www.baseball-reference.com and I missed it by 9 homers. I used to know everyone with over 400 lifetime jacks, but they are starting to slip away! I did not get everything I had planned done over my holidays, and I was worried about it for the last week, but now I have reached that nice resigned feeling that it will all be over soon. I like that feeling of the stress peeling back and leaving a layer of complacency that allows you to just do what you can and let the chips fall where they may.
We have hit full blown winter here in the South. It is supposed to hit 15 degrees tonight. After leaving the library tonight about 12 hours after I got to school this morning, I trudged the half mile or so to my car in the dark and bitter cold. (Don’t laugh you Indiana and Illinois guys, and I won’t laugh when you cry about how hot it is next summer!) It sure was different then the great fall evenings when I still had a few hours of sunshine when I left school and could think about pleasant diversions like firing up my grill when I got home. I think I have that syndrome where you get depressed when you don’t get enough sunshine. I’m not sure because we haven’t covered it yet in school. That is my standard reply to everyone who asks me medical questions anyway. People hear that you are in medical school and figure you know some stuff about their uncle’s disease. They don’t realize that if it is anything more than a lysosomal storage disease covered in biochemistry, they probably know more about it than I do. My stock answer to any question is “I don’t know – we haven’t got there yet.”

Oh well, it may as well be lousy weather; I need to lock myself in the library all weekend for the histology exam on Monday which I am currently totally unprepared for.