Histo study nook

Sometimes you just have to get out of your room. Especially when you need your microscope that's stored on the third floor of the Medical Education Building...

These classrooms always have people in them. It's after midnight on Saturday night (Sunday morning) and every room has 2-3 people in it. Except for mine! Maybe I smell or something. I probably scare them away as I dramatically mouth the lyrics to the musical soundtrack I have on in my headphones.

Study Aid #3

I promise: this is the last long weekend we have until Thanksgiving. From here on out, my posts should be more consistent.

I'm happy to have the time though as we have our second histology test and our first histology practical on Monday. We are one of the few medical schools that still uses microscopes and thus one of the few that still has a practical exam for this field. Whether or not that's a good thing is up for debate...

The diagram to the right is my new version of the concept map I made during my post-bacc year, seen below with the overlapping cellular pathways highlighted. We don't (yet) need to know as much as I needed to know for that old class and the pathways we do need to know have either been described slightly differently or discovered to be in fact different in the intervening years. It's nice to have this foundation to build on!

WILTIMS #38: Cheers!

Today was mostly centered on our Community and Preventive Medicine class, which means we covered important but often common sense information. Alcohol is bad. Smoking is bad. Exercise is good. Nutrition is important (though hard to pry out of a patient without eliciting a recall or sample bias).

TIL: Statistically, a given population is better served by an alcohol abuser developing a metastatic cancer than a benign one. It's a rather dark point, but because alcohol is one of the only high risk substances that, on average, does more damage to the people around the abuser than to the abuser his or herself, it's better that he or she develop and die from a more fatal disease than survive to put more people at risk.

An enormous Taiwanese research study showed that 15 minutes of modest exercise a day adds 3 years to a person's life expectancy.

The US Preventive Services Task Force is finalizing a new standard screening test (like colonoscopies and mammograms) for early detection of lung cancer in high risk individuals. As 85% of lung cancer is associated with cigarette smokers, this would be the chief group affected by this recommendation. The test itself would be a low dose CT scan which has been shown effective in finding early stage rumours. Lung cancers have a very poor prognosis, but are much easier to treat if caught early, so this could have a big impact.

WILTIMS #37: In need of an atlas... no the other kind

A drawing from my Netter Atlas of  Human Anatomy

As usual, the day after an intense test we are buried under an avalanche of new information. In anatomy, we have moved on to the back and extremities. But there are no organs, you say? Should be a cinch, you add? Pfft! There are more muscles and nerves than you can shake a stick at... and you'd be using dozens of them to shake the stick in the first place.

Anyways, lots of new info means a bunch of cool facts for you guys! Enjoy.

TIL: The first vertebra is called the atlas because, like the ancient Greek titan of the same name, it holds the globe in its hands. The weight of the entire head is balanced on just the two articular surfaces of this bone.

Statue of Atlas at 30 Rock

The axis is the 2nd vertebra and it has a structure called the dens which reaches up into the atlas, providing support analogous to the vertebral bodies of lower vertebrae. If a person's dens is abnormally long, it can pierce the spinal cord upon hyperflexion of the neck, killing the person "which can be a problem," as per my professor today.

Another developmental defect can be the formation of the ponticulus posticus, a small abnormal bridge of bone on the atlas that can cause a presenting person to pass out by pinching off the vertebral artery when they tilt their head back too far. This defect is more prevalent in women and can be found while at a hair salon when the hairdresser goes to wash the woman's hair and she loses consciousness in the chair.

There is a set of muscles in the back that do nothing, or rather they don't move anything as one would expect a muscle to do. These muscles have instead been found to be proprioceptive, meaning they provide sensory input to the brain about their relative level of tension, allowing one to better gauge the stresses being placed on one's back.

The lower part of the spinal cord looks very similar to the tail of a horse and thus is quite literally named cauda equina or "horse tail" in latin.

WILTIMS #36: Brain Pain

Not much was learned today as it was an exam day for Anatomy. And it was not an easy exam... or so I thought. The average turned out to be nearly 90%! We apparently know our stuff, even if we don't know that we know it. It's amazing to me, as someone who never really studied for anything in undergrad, that I can put my all into this class generally and this test specifically, study for weeks and for the entire four-day weekend prior, and still not feel confident walking in or out of that test.

I think the most embarrassing part of the day was when I couldn't identify the item picked out on my cadaver - on my half of my cadaver! I had no clue what nerve they had picked out. No one else seemed to know either though, so that made me feel better.

 TIL: Tests continue to suck.

Jamaican patties are quite tasty!

Study Aid #2

Click to go to the full sized map

We're in the midst of another four day weekend that is perfectly situated for studying for our anatomy test on Monday. I wrapped up yesterday's study session with a midnight cadaver poking session. Tonight, I decided to make a concept map of all the vasculature we need to know for the upcoming exam. I'll probably keep tweaking it but I thought I'd share what I've done so far. A nervous system map will probably follow tomorrow...

WILTIMS #26: Got Monson?

Today in anatomy, we had a lecture on the perineum (the lower pelvis) and in histology we tackled the classification and development of blood cells.

I also decided to run for one of the first-year Student Senate positions and had to give a speech to my classmates. Well, I had to give a speech, at least; the classmates were mostly absent. Of 200 students, 15 are running for 5 spots on the Senate. About 20 non-candidates showed up for the speeches which were merely off the cuff comments in which each person essentially said that they have lots of leadership experience.

The winners will be announced on Monday. I eagerly await finding out if my student election losing streak from junior high will continue.

TIL: Healthy adults produce 10,000,000,000 red blood cells every hour.

When someone is diagnosed with any stage of testicular cancer, the first thing that's done is the excision of the diseased testis*. Conveniently, the testes are extremely accessible through the scrotum, right? Wrong! The testes and scrotum actually have totally separate lymphatic drainage. This becomes important with cancer because any metastases flow through the lymphatic drainage and get caught in the downstream lymph nodes. So, the last thing a surgeon wants to do is expose a second lymph bed to possible metastases by dragging the cancerous testis through the scrotum. Because of this, every orchiectomy (testicle removal) is performed through the abdomen.

*In yet another example of complicated terminology for no good reason, testis is the technical anatomical term for a testicle. They are completely synonymous.

WILTIMS #35: The large and small of medicine

I'm not sure what changed exactly, but histology lab didn't seem quite so useless today. It may have been that the subject matter, lymph tissue, was less familiar to me from a histological perspective, a fact that was helped by my profound inability to stay awake during the related lecture yesterday...

At lunch we had a guest panel about the Affordable Care Act (Obamacare) and how it will affect us as practitioners. It's been interesting seeing how doctors around here feel about that law. The consensus seems to think that the law has many problems that still need to be addressed and will dramatically alter how we practice medicine, but that anything is better than the system (or lack thereof) that we already had in place.

We also had a guest lecturer from NYU School of Medicine who came to present some case studies that illustrate health disparities endemic to our health care system that will be our job to help fix. Examples were of the poor, uninsured immigrant population who may have a (rightful) distrust of our system and of the homeless who are sometimes understandably non-compliant regarding follow-up orders.

TIL: Social workers are the unsung heroes of medicine (I already knew this but it bears repeating).

The high endothelial venules of lymph nodes and the venous sinusoids in the red pulp of the spleen are analogous structures that allow for the selective perfusion of blood into the lymphatic system.

WILTIMS #34: The Yankees and Kosher Psoas

First of all, I realized that in my sleepy stupor last night I slipped into serious medical jargon for one of my stories in yesterday's post. I do try to keep things as accessible as possible to the less medically inclined, but on occasion I slip-up. Feel free to comment or email me if you ever need clarification.

Anyway, we had a fun New York moment in class today when our professor showed us an x-ray of a liver with many lesions and asked us what we thought was wrong. She decided to pick on a Yankee fan in the audience by asking him what the best baseball team in NYC is. He got the answer purposefully wrong, as the radiograph was of metastatic tumors (aka mets). For the rest of the lecture, whenever metastases were the correct answer, she continued to call on him and he defiantly answered Yankees every time to much
laughter.

TIL: People that maintain a strict kosher diet can't eat your average filet mignon.

The radiologist member of our anatomy faculty, being militantly vegetarian, loves to point out where each cut of meat can be found in the human body. When we had her for the thorax block, she pointed out that the next time we eat ribs we'll be able to identify the three muscle layers, the connective tissue and probably blood vessels and nerves. Yummy!

Today she pointed out that filet mignon is cut from the psoas muscle which connects the lumbar (lower) spine to the femur in the upper leg and is responsible for various hip movements. She then explained with the help of one of the many yarmulke-wearing gentlemen in my class that this muscle technically isn't kosher because some nerve/tendon runs through/near it. The details were confusing and my follow-up research (seen below) didn't help.

Translation of Genesis 32:32 - I asked for another translation, only to be more confused.

Another classmate then explained to a couple of us the reason for this seemingly random kosher rule. According to the Bible, Jacob fought an angel at the Jabbok River and suffered an injury to his hip that gave him a limp for the rest of his life. Somehow this injury was blamed on part of the psoas muscle, for reasons that aren't readily apparent. Now to remember this story, they don't eat that cut of meat, unless they can find a really good butcher who can cut out... whatever it is that makes it non-kosher.

To the Jewish folk I know out there: if you can clarify anything in this post, please comment!

WILTIMS #33: Gun and Knife Club 101

I was looking forward to today all weekend because of the title of our first lecture, "Blunt and Penetrating Trauma - Anatomical Considerations." It was every bit as gruesome as I had hoped, and more educational than I had expected. In order to predict the extent of injury for a stabbing or shooting victim, you really need to know your anatomy. I'll describe some of what we saw below, but as I know some of my readers would be averse to a gory slideshow, instead of blood and guts, each will be accompanied by a picture of my sister's adorable beagle.

A guy is stabbed through the middle of the chest. The most important piece of info we could glean from the picture was that the guy was alive and breathing. With this and the entry point location, we could piece together the most likely scenario playing out inside his chest. The knife was most likely (miraculously) wedged between the heart and diaphragm. Had it hit the heart it would have pierced the right ventricle (which would have killed him instantly or caused cardiac tamponade (which would have still killed him pretty quickly)).

A woman suffers blunt force trauma to the abdomen following a car crash. The CT scan shows a hematoma around the spleen. Where do you put a catheter to stop the bleeding while you repair or excise the damaged tissue? You find the celiac trunk coming off the abdominal aorta and then inject die to locate and block the splenic artery. But to be thorough, you must remember that the spleen can also get blood from anastomoses with the left gastric and left gastro-omental arteries. Depending on the location of the bleed, these other blood supplies could be important to the outcome of the case.

A soldier is shot with .22 rifle through the chest. How much damage does it do? Gunshots cause two types of damage: they create a hole following the flight path of the bullet, and they create a shockwave through the surrounding tissue, which can be just as damaging. With a high enough velocity round and a path along the anterior-posterior access, the shockwave may not have time to develop before the bullet exits the body, so you may only have to worry about the permanent cavity. If instead the victim is shot in the side, you will have to assume that extensive fragmentation and trauma from the shockwave will have occurred concentrically around the bullet's path.

TIL: How to place basic sutures and tie basic surgical knots. It's amazing how quickly I went from "I have no clue what I'm doing," to "I could do this in my sleep."

Special thanks to my sister Samantha for the distracting pictures. Please check out her blog too!

WILTIMS #32: TGIF

I'd like to start by reiterating that med school is awesome. Anyone interested in practicing medicine has been told by the old and jaded that it's not worth it - that medicine has changed from the glory days of the 50s or the 90s or last year. Never listen to these people. Find another mentor (who is preferably caught up on sleep) and don't stop until you track down someone who practices for the right reasons and will support your exploration of the field. I apologize in advance for those days when I'm the sad, tired representative of medicine, because I know this has happened before and will happen again. Anyone reading this has permission to give me a cold hard (hopefully figurative) slap to the face to remind me of how great I have it.

Anyways, today was fun and mercifully relaxing. We had a quick lecture on the male genital system with far too many cringe-worthy surgical videos and then a relatively simple dissection of the pelvis. I was done with classes on a beautiful Friday by 12:10!

TIL: ...our cadaver's name, age and cause of death.

An enlarged prostate is a pain in the butt, sometimes literally. It can block the urethra, grow into and plug-up the bladder, and/or push against the anterior wall of the rectum. The rectum is a surprisingly smart organ and can use pressure alone to deduce the consistency of its contents, allowing us to tell the difference between feces and gas. “But,” as my professor put it, “it don't speak prostate.” When the prostate pushes against the rectal wall, the rectum misinterpreters this as an ever present buildup of feces and signals you to head to the nearest toilet. However, since you have nothing to expel, you can never relieve yourself.

Pedunculated means extended from a stalk.

This last one comes with a warning: don't be stupid. You know how the Viagra commercials all recommend going to the doctor if one's erection lasts longer than 4 hours? Nothing actually happens at 4 hours. The reason they have that warning is because it takes 8-12 hours for tissue to die. Remember the tissue in this case is the penis itself(!), which is being cut off from circulation by the engorged erectile tissue. The only reason they don't tell the public the real timing is that stupid people would put-off coming into the doctor until hour 12 or 13 which is too late.

WILTIMS #31: Dishevelled Cellular Pathways

Click to view the original

The above is a concept map that I made during my post-baccalaureate year while studying for the final in a class called Cell Proliferation, Senescence and Death. It was a fascinating, if overwhelming class but boy am I glad to have taken it because, sure enough, the pathways are part of my histology/cell biology class in med school.

My favorite proteins from that chart are Frizzled and Dishevelled, so named because in the Drosophila fly they coordinate the alignment of hairs.

TI(re-)L: Bad/Bid/Puma inhibit Bcl-2 which down-regulates BAX/BAK which causes Apaf to dimerize in the presence of Cytochrome C, activating Caspase-9, leading to the further activation of Caspase-3 which triggers apoptotic cell death, possibly preventing the development of cancer. Simple!

WILTIMS #30: Non-Immaculate Volcano

You know it's a long day when you have to be at the Medical Education building before it unlocks and you don't leave until it locks again for the night. We started the day with our one and only biostatistics exam at 8am. One class down! I think this is the third time I've thought I was done with math classes forever. And sure enough, I found out that we will have another round of biostats next year.

After a few bouts of anatomy, we had our first clinical practice sessions on taking a patient's history. This involved small groups and role playing and was surprisingly fun. As another example of medical education relying on students just winging it at first with very little preparation, we initially had no idea what we were doing. But after an hour playing both the doctor and patient, we quickly and noticeably improved. I for one learned that when my fake-patient responded to my question about her father by saying he didn't have one, I probably shouldn't have responded "So... immaculate conception?" but instead have tried something like, "Is your father still alive, or estranged, or did you know your father?" Who knew!?

The required reading for this class has a nice sense of humor too. When explaining how to start with open-ended questions, the book recommends something like, "What brought you to the hospital?" but then warns: "Although this question may be subject to concrete answers like, 'A taxi.'" I love that it acknowledges smart-ass patients.

TIL: The rupture of an ovarian cyst is the exact same pain as being kicked in the testes*.

When a C-section is performed, the amniotic fluid bursts forth from the uterine incision like a dirty Gatorade volcano.

*You can tell I'm becoming a professional because (after ten minutes of debate) I did not call them balls, nuts, cojones, etc.

WILTIMS #29: Radiology saves the day, again!

In another show of the tedium of histology, here's my quote of the day: "They called the protein cyclin because it cycles through the cell cycle."

Thankfully, during the afternoon we had an anatomy lecture taught by the coolest radiologist. She is very big on teaching using case studies and participation rather than straight didactic presentations. Generally, her lectures give a little background information and then transition into her guiding us through unknown radiographs. And by guiding, I mean having us guess what's wrong with the patient at whose scan we are looking and then telling us why we are wrong or right (but mostly wrong) and then giving us candy regardless. She's great at turning a stupid guess into a valiant attempt with solid, though flawed, reasoning behind it.

Some fun pathologies we saw today included the “apple core” presentation of colon cancer, the blockage of the ileocecal valve between the small and large intestine by a large gallstone, and the pinching off of the duodenum of the small intestine by an annular pancreas. This last one is especially cool because it only makes sense if you know the developmental history of the pancreas. The pancreas actually starts out in the fetus as two smaller glandular organs on the right side of the abdominal cavity and, as the mesentery rotates during development, the two proto-organs merge into one and settle on the left side of the abdomen. If, however, these pancreatic pieces get tangled around the duodenal portion of the small intestine, they can block-up the whole GI tract, resulting in intractable vomiting for the infant in question. 

TIL: If the sigmoid colon is enlarged from years of constipation, it can twist itself off exactly like a balloon animal's legs, causing the colon to occlude and fill with gas. The characteristic x-ray image for this condition, called a sigmoid volvulus, looks like a giant coffee bean that points to the right upper quadrant of the abdomen.

WILTIMS #28: “Ooo, look at this! Isn't this awesome?!”

Let's get this out of the way right now:

TIL: To remove a champagne glass from the rectum, you can fill the glass with plaster of Paris and a tongue depressor. After relaxing the anal sphincter and allowing the plaster to set, you can pull the glass out without breaking it. The more you know!

Today was awesome. Disturbing at times (see above), but one of the most inspiring days to date.

We started the day with an anatomy lecture on the urogenital diaphragm and the female perineum. We then dissected the same up in lab, which was not easy. This was one of those lessons for which the takeaway was that we can't really see any of the important structures, but we still need to know them. Also, cadavers do not assume the spread eagle position with ease, so we had to use wood blocks to brace the legs apart. Not exactly a tasteful position...

Today was also the first time we had to flip our cadaver! The only noteworthy thing about this is that the entire posterior surface of the body had filled with fluid and flattened against the metal table. When we first flipped our body, it was flat as a board from the thighs to the shoulders, except at certain intervals where the skin bunched up, like a poorly ironed shirt. After an hour or so, some of the curves of the skin returned, but it still looked rather boxy.

The highlight of the day was an extracurricular activity for which some members of my class volunteered to introduce students from the speech/pathology school on campus to the anatomy lab and our bodies. These students will be taking gross anatomy in January, but are typically totally new to hard sciences and lab classes, so to them, even with only a month of experience, we are the experts. This was the first time we were able to show off what we had already learned, while trying to de-scarify (that's a technical term) the idea of working with cadavers.

I had the bonus of getting to explore a new body because we had more than one student from our group and the adjacent body had no one. This made it so that I could explore the body right along with the speech/pathology students, and be genuinely enthusiastic when we discovered peculiar anatomy or pathology. I had a blast with this and really surprised myself as to how much I have already learned.

WILTIMS #27: Well, it's been a long, been a long, been a long, been a long day...

First and foremost, an election update! ...I lost. The streak continues! Well, I shall take solace in a quote from my favorite author:

“The major problem --- one of the major problems, for there are several --- one of the many major problems with governing people is that of whom you get to do it; or rather of who manages to get people to let them do it to them. To summarize: it is a well known fact, that those people who most want to rule people are, ipso facto, those least suited to do it. To summarize the summary: anyone who is capable of getting themselves made President should on no account be allowed to do the job. To summarize the summary of the summary: people are a problem.” ~Douglas Adams, from The Restaurant at the End of the Universe.

Secondly, in regards to my prior and upcoming lack of posts, we have, or should I say, had very little school this week, with Labor Day on Monday, a random study day yesterday and Rosh Hashanah starting tomorrow. In fact, the only class we had was our hellish 2½ hour long histology test this morning.

The test was brutal, in part because it covered so much material. Last year, the first histo test was the day after the first anatomy test and everyone bombed it. This year, in order to “help” us, they moved back the histo test to give us more of a gap - the only problem being that we now had 20 lectures and 6 laboratory sessions of material to study. That's about the amount of material we covered in an entire 10-week course at UCSB condensed into not quite 4 weeks.

I am cautiously optimistic that I passed, but I make no other claims.

TIL: If doctors make the worst patients, soon-to-be doctors are in training to compete for that title.

The bus to Ithaca from White Plains is really not too bad and fairly convenient. As with any long haul bus, the passengers are wonderfully diverse and entertaining. I met a man named Alan who looked very good for his age (he told me so himself), listened to a woman who started smoking a cigarette to try to jinx the bus into showing up, and was late to one stop because the bus driver got lost between the freeway and the depot and had to ask directions from people on the street to figure out where he was going.