opposites

Studying can get more than a little bit monotonous, especially when reviewing and having no old tests to go off of, so I try to spice it up by studying in different locales, trying different techniques, etc. For instance, I typed up some tables and such and then had my wife quiz me over them. "Oh, I don't know. I'm not as smart as you doctors. I might not do it right," my wife sardonically replied. She thinks it's funny to constantly make fun of how smart we med students are knowing full well my opinion on how many stupid smart people there are. If you set out to design polar opposites, you couldn't do a better job of me and my wife. We're as far apart as up from down. I'm linear and analytical. She's spontaneous. She'll pull questions that aren't even out of left field. Hell, they're not even in the ballpark. They're more from the bar three blocks down from left field. But I've learned that if I can explain something medical to her, then I must know it pretty well. The opposite is true, too. If she pulls a question from said bar three blocks down and I can't answer it, well, I need to expand my knowledge. Life is funny in the timing. Last night, she's helping me review and we get to the GABA pathway. I explain to her that drugs that mellow people out like valium or the infamous date-rape drug rohypnol, work by accentuating the effects of GABA. GABA is a signal that blocks stimulation. Everything mellows out. That's why they're used to treat anxiety. They're inhibiting those stimulus signals that are driving the anxiety. And out of the blue, she asks, "So is this what alcohol does? (without giving me time to even answer, this is how her brain works) So you could give this to an epileptic to stop their seizures?" "No idea. I suppose it might work." I'm not kidding. The VERY FIRST question on the written portion of the neuro exam: Patient presents to the ER with acute seizure. What might be a good treatment option in an acute event? A) don't remember B) GABA agonist like benzodiazepines I had to bite my lip to keep from laughing myself out of the chair right then and there. So I google it when I get home (again, how did med students learn before google?) and sure enough, benzos while not a first line option for chronic management of seizures because they tend to become less effective over time, ARE often used for prolonged seizures. Too funny. There's a piece of clinical information I won't soon forget, just because of my wife. The magnetic force of polar opposites ain't a bad thing.

neuro exam

The neuro exam is split into two. One half is a written and one half is a practical. The practical is a bit of new experience for me. Last semester, we had a practical for histology/cell biology but that was fairly straightforward. The prof showed us what to know during a review before each exam and then during the practical, sure enough, he'd throw up a slide that encompassed that material and ask a question over it. Neuro is a bit more....disjointed. We have a piece of homemade software that's pretty helpful for identifying parts. The downside is that if you want to be tested on the stuff on page 38, you have to ID the 37 other pages of crap first. Overall, though, I have to say I like it. It's much more interactive than just staring at an atlas. In case you're wondering, that structure in red that I identified is the Anterior limb of the Internal Capsule. I know that y'all were dying of curiousity to know that.

The actual wet brain part, though, is abysmal. We have a TA show us in a huge group some tiny little structure and then quickly move onto the next structure. Not very conducive to learning at all. So going into the practical, I feel comfortable about diagramatic questions. Real isolated brain parts? Not so much.

The practical exam is a giant organized game of musical chairs. You sit down at a station with your clipboard and answer the question. 60 seconds later, a musical chime goes off and everyone stands up and shuffles to the next station. Repeat about 70ish times. Oh, and the best part was that there are rest stations when you have to switch rows so you don't have to worry about not having enough time. I started at a rest station and the first three sections were 90 seconds, instead of 60 seconds so that people could get used to it. So I get to sit there for 90 seconds waiting for the doom to start the exam. That's a lllooonnngggg 90 seconds. The prof comes up to me and says that it's like I'm a kicker and a timeout has been called so that I can sit there and overthink it. "Icing the kicker" it's called. It works.

exams away

"This exam is just 40 questions, right?" Most around me agree until someone behind me says, "I think it's 80." Apparently, I didn't learn from my mishap last semester. Oh well, it can't be that hard. It's immunology after all. It's not brain surgery. The exam proctor reads out the instructions and I'm furiously bubbling my name in. Curse my long name! It's so long that it takes up every single square available. "I mark the time as 1:08. You may now begin." I'm still bubbling my alphabet of a name in as I hear students flipping the pages and beginning their exam. I look down at my watch. It's 1:45 and I'm done. 80 questions in 37 minutes? I look up and the lecture hall is still packed. I sign the honor pledge, pull out the ear plugs, walk down to the front and hand in my test. It's the first one handed in. Uh-oh. That's either a good sign or very, very bad sign. Honestly, I'm hoping for an 87-90 but after finishing that quickly, I don't know.

exams

I haven't blogged much because I'm cramming for the block I exams. Normally, I don't believe much in cramming but I had to out of necessity. I got sick right at the beginning of the semester and got about a week and a half behind. So I crammed away. This semester is different for me in another way, too. For immunology, the most recent old test to study was from 2003. For neurology, it's 1993. Needless to say, I'm guessing the questions and format have changed just a bit in that time period. As a gift from the class that preceded us, they gave us a dvd with a bunch of goodies. One was a guide on how/what to study for each class. For neurology, it's "memorize the syllabus". That's great. The syllabus for block I is 160 pages worth of material. Let me just commit to memory right quick. And that doesn't count the lab. Don't get me started on the lab. Never have I had a more disjointed, schizoid if you will, lab. Most of it is spent not analyzing and picking apart a brain like one would expect. No, it's all software stuff that where we're constantly being interrupted by the instructor or TA to spurt out some completely unrelated material or to take the two timed quizzes at the end of each lab. Well, back to cramming.

death

My wife's uncle recently passed away after struggling with multiple health problems. In addition to the pain associated with watching a loved one hurt, my wife; as I listened to the funeral, I was struck by how limited the medical field truly is. Despite our massive breadth of knowledge, our armament of drugs, and our ever increasing technology, there are many places in life where it falls utterly short. Her uncle suffered a mild heart attack some years back. About 18 months ago, he suffered another heart attack while also having a stroke. Somehow, he pulled through despite now missing part of his skull to alleviate the swelling in his brain. Then about 6 months ago, he had a lower leg amputated at the knee due to wounds that just wouldn't heal (stroke side and he was diabetic). He finally succumbed to an infection that went systemic. The funeral was in a small evangelical church, very informal. Several church members got up and recounted their relationship with him. Basically, it started at the time after his stroke when he was confined to either a hospital or rehab center. So here are people who did not know him, but knew his sister, and so reached out and visited him. They did something that medicine was unable to do. They tried to comfort him during his last year. The doctors threw everything medical they had at his condition but could only delay the inevitable. But I wonder, during that last year of his life, which mattered more? Did all of the hospitalization and medicine matter more than the human touch, even from the kindness of strangers? Then again, the hospital did keep him alive for another 18 months and did provide the opportunity for those individuals to comfort him. How many of us would turn that down? But even if in pain and suffering? And what about the family members? They're torn between wanting, hoping against the odds that their loved one will get better contrasted against the pain of watching them suffer and get progressively worse. I'm not sure of my own answer. It's not a clear black and white decision. No one knows ahead of time what degree of suffering is coming. Or, what level of joy is possible through extension of your relationship with loved ones. It just seems that our culture hasn't provided much in the way of dying well. I watched it with my grandfathers on both sides of the family, as well as when I volunteered with hospice. Pain is ever present and little is done about it. I don't know how much training is given to docs on assisting others with death but I'd wager it's very little. It's made me think that at some point of my training, I'll need to seek that training elsewhere. I shudder to put myself in the position of his attending, trying to balance hope with realism, allowing the family to grieve while feeling like they're not giving up. That's a tough path to nagivate.

what do you mean, it's only been 3 minutes?

As the sun slowly crept over the horizon, it'd start to peek through the window and land on my desk at the back of a thrilling 8 am freshman calculus class which met 5 days a week. Tilting my wrist, I'd place my watch which had a pyrimidal glass cover into the ray of light creating a kaleidoscope of colors on my desk. The dilemma was to avoid actually looking at the time on my watch, a present from my then girlfriend and now wife. I swear it had frozen still. Surely, it's been at least half an hour. Nope, 3 minutes. Med school nowadays is so much better. Magical even. I can watch the lecture from home, not having to fight rush hour traffic commuting down to the medical center. It gets better. With technology, there's no slowing down of time as the lecture drones on. In fact, I can speed them up! Ain't technology grand? I watch them at 1.5 times the regular speed. A 50-minute lecture now takes 33 minutes. (Some students watch it at 2x speed.) It's getting to the point that listening to a real time lecturer sounds like I'm listening to a turtle. The voices are pretty interesting, too. Some lecturers who speak slowly actually sound better at accelerated speeds. Those who have higher pitched voices or who speak rapidly present more of a challenge. Accents are hard, too. I'm inherently lazy so anything that can speed things up and make it easier are great in my book.

This is normal speed.

And this is at 1.5x speed. I've done some at 1.6 but I haven't gotten good enough to go at 2.0. It's too hard to take notes then because you miss the next 30 seconds in the time it takes to write something down.

health care debate

At first, I thought that solving our medical system would be near impossible due to its complexity. But the more I thought about it, the simpler it seemed. This video seems to present a pretty good case for a potentially different direction. Unfortunately, we seem to be heading in the opposite direction which is a shame. Even if we adopted every single "reform" being proposed in either the senate or house, we're still headed for a financial train wreck. Say hello to serious rationing in the future. http://www.youtube.com/watch?v=3E29LD98ruo&feature=player_embedded

more on introverts

A couple of other articles on introverts and medicine. Not exactly encouraging. Careers for introverts in the medical profession. Notice they don't list MD or RN. Another blog from a med school student who happens to me an introvert. Again, not exactly encouraging. Then again, both my dad and my wife don't think I'll last very long at actually practicing medicine. Don't get me wrong. They both think I should go through with it. They just think I'll end up doing research or something else other than solely a clinical practice. Honestly, that was one of the big appeals of the path. Even my former VP, an MD, told me that's the beauty of it. If you don't want to practice, you don't have to. There are plenty of options available.

zzzzzzz

This week has been horrible. Mostly, I've gone to bed around 9 and then dragged myself out of a nyquil induced coma before noon. Haven't got much done at all. And this artic cold weather is just lovely on my already compromised sinuses.

Ice just isn't something you see in Houston. The only time we're supposed to see temperatures in the teens is if one's measuring in celsius. Hopefully, I can get caught back up because I'm wwaayyyy behind right now. I did drastically up the dose of steroid and that seems to have made a bit of a difference so I'm hoping that by tomorrow, I'll be something other than horizontal and filled with phlegm.

introvert

Fifteen years as I tried to register for classes, one class was unavailable but I needed something, anything and that's exactly what I got. Sociology 271 - Relationships. There were a grand total of 3 guys in the class and one dropped after the first day. A less than stellar class but I took one immensely important tidbit away. Our professor made us take the Myers-Briggs personality test. With disdain and an unhealthy amount of skepticism, I took the test. A week later, we got our reports back. Holy Crap! This report was reading me and telling me things about myself not even my mother would know. It was a bit disconcerting to experience the degree of accuracy. If you've never taken it, I highly recommend it. It was extremely informative to me. The biggest thing I learned was that I was an introvert of extreme proportions. In retrospect, that seems like a big no sh*t sherlock, but at the time it helped me realize that I wasn't misanthropic or a jerk, despite what others may have thought of me. It was extremely liberating to let go of the notion that I had to try to be something I wasn't. Part of it was I don't think I've ever come across someone as introverted as myself. All I saw were extroverts so that's what was normal. Most people, after all, are extroverts and I suspect that figure is even higher in medicine. Back to today. Every week in my inbox, an email appears from my school dubbed "Health on the Go". Usually, I briefly glance through it and when nothing strikes my fancy, I click delete. This last one had something intriguing. It was all about extroverts vs introvert with a sympathetic tone to introverts. "Three-fourths of all people are extroverts. And, unless they have mastered compassionate acceptance of all sentient beings, they think introverts are plain odd. Extroverts have little understanding of introverts. They assume the company, especially their own, is always welcomed and cannot imagine why someone would need solitude. Understandably, they have many friends and find it easy to strike up a conversation with strangers....There are definitely benefits to being an introvert. Introverts do better in college and graduate school. They divorce less and change jobs less than do extroverts. However, a study of 258 college students found that extroverts had higher self-esteem and fewer sleep problems." Definitely. Very few people have ever been able to understand me (myself included). I can't tell you the number of times people thought I was a complete jackass until they got to know me (well, most anyways). So next time you come across some one you think is a churl, give them the benefit of the doubt. They may just be an introvert.

physician, heal thyself

Pretty much every winter, I get a bad case of sinusitis which then may or may not lead into bronchitis. You name it, I've pretty much tried it all. Last year, from Thanksgiving up until February, I was in the doctor's office 5, count'em 5 times for recurring sinusitis. It finally took prednisone and leviquin (after low dose methylprednisolone and two rounds of antibiotics) to knock it out. This year, I was determined it would be different. I don't have sick days anymore. School keeps marching unabated. I had to figure it out. First, what doesn't work.

1. Letting it run its course. It starts viral but then after about 4-5 days, it goes bacterial and runs rampant.
2. Been to the ENT. Even had rhinoplasty to correct a deviated septum and hypertrophied turbinates. I can breathe better but the sinusitis didn't get better. It may have helped it from dropping into my lungs, though. CT scan post surgery shows clean cavities.
3. Asthma. Been tested and blew through the test with flying colors, though once it's in my chest, an albuterol inhaler does help alleviate symptoms.
4. Front line antibiotics like penicillins. Macrolides like zithromax are hit or miss. Flouroquinolones like levaquin have always worked. But it's always been paired with a steroid. Hmmm....
5. Nasal decongestants like afrin. It helps me to breathe but then the stuffiness rebounds worse after it wears off.
6. Antihistamines. More than one doc told me to "keep my allergies under control" and it'd help to prevent it from occurring. Nasal antihistamines may have role in the acute phase, though. Chronically, they make my nose bleed so that's out of the question. The other part was that it always hit me when pollen counts are at the lowest. Doesn't sound allergy driven to me. Doesn't work anyways. I've tried.

Last year's 5 trips was educational after a whopping one semester, well a half loaded semester, of med school. I'm feeling all edumicated now. #1 - It happens every winter, not spring or fall when I actually have bad allergies. It ain't allergies, though perhaps vitamin D may help. #2 - My family doc, who is very astute, used the term "reactive airway disease". Use that term with a lot of docs, and they'll roll their eyes. It's such a vague diagnosis as to mean nothing. But it did start get the little hamster running upstairs. Perhaps the infection is a red herring. I've been trying to treat the reaction rather than the cause. Perhaps the cause is not a weak immune system, though I definitely do have a pretty pathetic one. Perhaps the cause is an dysfunction of inflammation. The irritated mucousal membranes filled with dripping goo provide a nice environment for the bacteria to move in after the virus has already set things off.

So armed with new ideas, I've tried a few new ideas and combined them with older ones.

1. Vitamin D. In Houston, it ain't hard to get it in the summer and I made more of a conscious effort to use it. I never burned, I just got a bit of tan. Once the sun got lower in the horizon, I started taking oral vitamin D at 2,000 mg daily. It didn't prevent me from getting sick in the long run but I did make longer than previous years. Usually, it would hit me around October or November and then by late February, I was fine. This year, I made it until the first week in January. Not a complete waste.
2. Smoothies. One winter, miracle of miracles, I didn't get sick at all. In looking back, I was on an exercise kick and I had been drinking smoothies consisting of orange juice, berries (raspberry, blackberry, blueberry, etc), a banana, and whey protein. To paraphrase Bull Durham, don't mess with a winning streak.
3. Corticosteroids. Earlier in the semester, I felt a tickle at the back of my throat and a tightness in my chest. I immediately popped some pseudoephedrine, sucked on Cold-eeze and started 5 mg of prednisolone. I also snorted nasonex since it's a tad faster acting corticosteroid than prednisolone. After two days, the stufiness went away and the tightness evaporated. Since I don't have money for doctor's visits and hey, I'm technically a doctor in training, I had no problem making the call to administer myself pred knowing that I had to taper it off and use it short term. I've tried the combo without the steroid before with hit or miss results. This time it worked so I'm 2/2 with a steroid on board.
4. Cold-eeze are hit or miss for me. From my experience, I have to take them immmediately at the onset of symptoms for them to help shorten the duration. If I wait so much as a half a day, then nothing. I stay away from the nasal zinc like zicam as I'm not too keen on losing my sense of smell. I'm not aware of any cases of anosmia with zinc lozenges, though. Caveat emptor.
5. Nasal rinse via NeilMed. My ENT turned me onto this technique. I don't know how much it helps with the actual sinusitis but it helps my allergies IMMENSELY. It takes a bit of getting used to squirting water up your nose but if I forget to do it for a couple of days, I notice.
6. Sinusbuster. This is just plain lunacy. Then again, so is trying the same thing over and over and expecting different results. I had to find an alternative to afrin. Like I said, I'll try anything. If you didn't click on the link, here's the stupidity of it all. You squirt capsaicin, you know the stuff that makes jalapenos dangerous, up your nose. Makes sense, right? Let me take something that's going to irritate the hell outta my mucous membranes and shove it up my nose. Aside from the "mild discomfort" (if that's mild, I'd hate to see moderate to severe), I have to say that after I do the nasal rinse and then the sinusbuster, about an hour later, I can breathe much better than doing nothing or just the nasal rinse. Beware, it hurts like hell, though. At least it's only about 3-4 seconds. My wife always knows when I take it because I'm banging my fist on the shower wall. I'm not a total idiot, though. There is some data on it in humans. Not exactly high quality trials, small, need to be repeated, yada, yada...desperation will make you try strange things. Aside from obviously opening you up, it seems to have longer term effects by desensitizing your nose to irritants.

We'll see how it goes. The crud in my sinuses started on Sunday after a get together with friends. I'm also trying Sinupret. I haven't made up my mind on it yet, though there is some data in Europe on using it to treat chronic rhinitis with it.

thus it begins anew

The auditorium begins to fill in with students, most inquiring each other about how their respective Christmas breaks went. As usual, I take my seat in the back. As the lecturer starts to quiet everyone down, I notice in front of me that one student has their online syllabus already highlighted and annotated. Another has their printed syllabus with notes, as well. I just got my syllabus last night and hadn't even glanced at it. Nervousness begins to set in. I'm not prepared.I just got lucky last semester.These classes are different.Harder.....Am I capable? I thought I felt as nervous as I did the very first day of school. Fast forward to the end of a long day - it was dark when I left home and it was dark when I got home. As we filed out of an even longer lab session, I overheard one student remark, "that was....a bit rough for a first day." Indeed. My nerves had settled and reflection set in. While apprehensive, as I thought back to that first day, that first week, reality set in. I wasn't anywhere near as nervous then. I was an absolute wreck then. I lost about 10 pounds that week because I could hardly eat. Today, that anxiety lasted less than a day. By the end, I felt comforted that everyone else was just as lost as I was, well not everyone but most everyone. That growing confidence began to reassure me, you did it before and you'll do it again. Period. Backing out, failing, or hell, even mediocrity isn't an option anymore. I really am in this for the long haul.