WILTIMS #160: The end of the beginning

Assuming I survive my upcoming finals, in a little more than a week I will have finally survived my first year of medical school and one year of many on the way to becoming a fully fledged physician. I will post a more thought-out reflection when I have time after my exams, but briefly, thank you all for following along as I haphazardly tried to document and share a tiny fraction of what I've learned this year through sleep-deprived writing sessions.

I hope to keep writing on occasion through the summer on various health-related topics, but the next WILTIMS post will be in August as we start year two with pathology, pharmacology and microbiology. Please leave any ideas for future topics in the comments. Thanks again!

TIL: A lucid interval is a period of temporarily regained consciousness after a traumatic brain injury. Such a degeneration back into unconsciousness is highly indicative of an epidural hematoma.

Decerebrate posture is a worrying symptom where the patient will extend all their limbs and arch their back. This is related to decortication, another serious posture with the difference that the arms are flexed instead of extended. The latter often leads to the former and is thus similarly disconcerting. 

With certain conditions involving a protruding eyeball (aka proptosis or exophthalmos), you can place your stethoscope directly on the eye to listen for bruits (pronounced broo-ee). These turbulent wooshing noises would in this case indicate a vascular problem involving a high pressure tear in the internal carotid artery as it passes through the cavernous sinus (called a carotid-cavernous fistula).

WILTIMS #159: The beginning of the end

Today included our last didactic lecture of the first year. We have a neuroanatomy practical final tomorrow morning which begins two weeks of the typical hellish exams. I think tomorrow will be my final WILTIMS post of the year!

The other activity today was a behavioral health conference where we watched a psychiatrist interview a patient, for probably the eighth time this term (five of those times were in smaller sessions led by a student). Something I've learned from these encounters is that you never know if the important information will come out 5 or 45 minutes into the interview.

You can't explicitly ask the patient about every possible delusion or symptom. Most of the time is spent getting a feel for the person and trying to hit upon the biggest aspects of their current and past mental disturbances. The most out-there story might not be elicited until near the end of the time and by the most innocuous of questions. Learning the knack for stumbling upon those triggers is truly more art than science.

TIL: Certain bone fracture patterns are characteristic of child abuse. Since juvenile tendons and ligaments are proportionally stronger compared to bone than in adults, traction (pulling) or torsion (twisting) injuries can result in nasty fractures along the epiphyseal-metaphyseal junction (the ends of long bones near the growth plate). One such pattern is called a bucket-handle fracture, seen to the left.

WILTIMS #158: Unexpected effects

Aprepitant is a designer medication that was made to be the end-all, be-all in pain relief by antagonizing Substance P, a neurotransmitter associated with nociceptive (pain) responses, among others. It was horrible at that. They then tried using it as an antidepressant and it failed miserably again. Showing true determination (or desperately trying not to write-off a billion dollars in useless research) they tried it on chemotherapy induced nausea and I am so glad they did. It actually worked. And 9 years later, a young man with Hodgkin's lymphoma was finally put on it after weeks of crippling chemo-induced nausea.

I do not miss this hair-style

That story snuck up on me in class. It was only after I looked up the generic name for the drug that I put together that I had just heard to origin story of my pharmaceutical savior from a couple years ago. Then, in part out of sentimentality and in part because the lecture was (present story excluded) supremely uninteresting, I started thinking about how far 2 years has brought me.

One of the anecdotes the professor used to explain chemo-induced nausea and its complex relationship with diverse brain structures was that cancer patients can often feel nauseated just walking into the hospital. This hit really close to home. There was a time during my treatment that I was seriously concerned that I might not be able to pursue my dream of practicing medicine because that sterile hospital smell made me want to puke. It was maddening. My very logical brain knew as I shuffled down the hall that I hadn't yet received any medication and that I had worked, volunteered, and sniffed around for thousands of hours in hospitals. My brain was betraying me and making me hate and fear something that I loved.

The other less-than-happy feeling was some sort of unreasonable guilt for not having received an acceptance to medical school. Every week the nurses and doctors would look expectantly when I opened the door, ask if I had gotten in, and every week I disappointed them. I didn't get in that year, but the celebration was wonderful a year later when, as a volunteer in remission, I came into the unit and went to my favorite nurse. I asked her to ask me the question one last time. After a brief pause and confused look, I got the biggest teary-eyed hug. And not a year after that, I'm learning about the treatments I was receiving so recently in that very unit.

So to sum-up: lecture was really boring this morning.

TIL: Many neuropeptides are aminated at the C-terminus to avoid decomposition by carboxypeptidases.

Melanocortin receptors are all G-protein-linked receptors which increase cAMP levels.

WILTIMS #157: Sleep, gender, and sex

TIL: People with narcolepsy can have hypnagogic hallucinations. This is essentially REM sleep happening when they are awake. Put more plainly, they dream while awake.

Cutest narcoleptic dog ever

There are many survivable sex chromosome aneuploidies, instances where an individual is born with combinations other than the usual XX and XY pairs of sex chromosomes. Two are common enough to have named syndromes:

• Turner's syndrome: XO, externally female, short stature, infertility, webbed neck
• Klinefelter's syndrome: XXY, externally male, tall, infertile

Orgasmic disorder is really counterintuitively named. Rather than being some sort of euphoric condition, it is actually the inability to achieve orgasm.

Frotteurism is a sexual disorder where a person is aroused by rubbing up against a stranger in public.

Harmless paraphilias (i.e. shoe or furry fetishisms, not necro- or pedophilia) are not disorders unless the fetish is the only way for the person to achieve sexual gratification. In other words, you are aloud to have a kinky streak but if you need it to enjoy any sexual activity, you may have a problem.

WILTIMS #156: Sunshine and GBS

Today I volunteered with yet another campus organisation, our school's chapter of Project Sunshine. This is a group that goes to a local children's hospital to play and hang-out with long-term pediatric patients. Got my but kicked both on the Xbox 360 and the air hockey table. Yay for ALL the extracurriculars!

TIL: Guillain-Barré syndrome is a peripheral neuropathy caused by an autoimmune reaction that targets the myelin around peripheral nerves. This causes progressive numbness in the extremities that starts at the hands and feet, before advancing toward the torso where it quickly becomes life-threatening. In this way, progressive arm or leg weakness can be an omen of sudden respiratory failure. So, there's a nice fact for all you hypochondriacs out there!

WILTIMS #155: 608 points from the corner

TIL: Always laugh at an attending's jokes (even if he's being an egotistical ass and rehashing stupid puns).

Stupor is a stupidly general term meaning any depressed state of consciousness between coma and normal awake.

A coma is different from a vegetative state. A coma is being unconscious and unarousable whereas patients in a vegetative state are still partially arousable - for instance they still go through normal sleep and wake cycles. When aroused, a vegetative patient has no awareness; to make a crude metaphor: the lights are on but there's no one home.

Urbach-Wiethe disease is an extremely rare condition that causes all sorts of problems. One of the more curious possible symptoms can be nearly complete fearlessness, caused by the bilateral calcification of the amygdala resulting in

Pseudo-bulbar affect its a condition described as a disconnect between emotions and outward behavior (e.g. inappropriate laughing).

Félix Vicq d'Azyr, besides being the all-time winner for highest per letter scrabble score for a name, was a French physician and anatomist who first identified several structures of the brain. He was particularly well known for describing aspects of the limbic system, including the mammillothalamic fasciculus, also known as the bundle of Vicq d'Azyr.

WILTIMS #154: The interviewee becomes the interviewer

Today I had my last behavioral health clinical conference at our main teaching hospital. These are the sessions where we split into groups of ten, disperse around this and several other hospitals, and watch as one student interviews an actual psychiatric patient about their life and the difficulties that led to their inpatient stay. Typically, there are also a couple other students either on their third year psychiatry rotation or part of a different program. I reluctantly volunteered to do today's interview and it went surprisingly well.

While I sat waiting for the overseeing doctor to fetch the patient, one of the third year students turned to me and asked, rather cryptically, "Do you remember me?" Though she did seem vaguely familiar, I couldn't think of any reason I would know a third year, let alone why a third year would know me. She continued, "I interviewed you last year."

Now, in a flash of confusion due to the setting and an overactive imagination, I briefly thought, "But I haven't ever been a psych patient..." before realizing that she had in fact been one of my interviewers for admission to this med school. Our school uses the multiple mini interview (MMI) system, with eight rapid-fire six-minute sessions. The interviewers are a diverse assortment of people including professors (both researchers and physicians), administrators, and often one student. Recognition finally dawning, I told her that I did, in fact, remember her and the questions she asked me.

She, and I'm not making this up, said that she remembered giving me the highest marks of all the interviewees that day. I abashedly thanked her and pointed out that she may have made the difference that put me in the seat next to her today. How's that for a nice boost of confidence before taking the hot seat?

TIL: Psychosomatic medicine is a subspecialty of psychiatry, formerly known as consult-liaison psychiatry, that deals with the interplay of psychological disorders with medical ones. This can mean both psych symptoms as a reaction to a medical diagnosis and physical symptoms experienced as a manifestation of an underlying physiological illness.

WILTIMS #153: Reed Wada Broca

TIL: Walter Reed (as in the guy after whom Washington DC VA hospital is named) was a dick. He and several other medical researchers decided to study yellow fever. After the first attempt at studying it by infecting themselves proved too dangerous (one researcher died but Reed himself was never exposed), they turned to requesting volunteers from the army. Men were paid and promised medical care and a government pension should they survive the infection. The whole study was dubiously ethical at best.

The Wada test is used to determine left/right brain dominance with the speech and language centers of the brain. A drug called sodium amobarbital is injected in one carotid artery, silencing that hemisphere of the brain. The side that retains the most function when the test is done bilaterally, is dominant. For right-handed people it is the left brain 95% of the time; for lefties, the left brain is still more likely to be dominant but only 65% of the time. Dominance is important to establish when neurosurgery needs to be performed, in order to minimize damage to these important loci.

Broca (as in Broca's aphasia) proved that speech and language are localized in very specific centers in the brain. Prior to his discovery it was thought that these processes were processed diffusely throughout the cortices.

WILTIMS #152: Professional beliefs

In general (everything that follows is a gross oversimplification of a diverse group of people), physicians are an interesting sort of libertarian. They make a very good salary and thus tend to be fiscally conservative. But they also see daily the pains of the disenfranchised and socially marginalized members of society and are very socially liberal. This often makes for weird conflicting positions like a desire for universal healthcare but with lower taxes.

As evidence for the social positions, our school has entire classes built around dismantling community health disparities. We have had at least 3 lectures this year dealing exclusively with the specific medical and psychological concerns of LGBT patients. And this isn't just a vestige of our admittedly liberal-leaning location. The American Psychiatric Association removed homosexuality from the DSM (Diagnostic and Statistical Manual of Mental Disorders, aka The Psychiatrist's Bible) in 1973. A topic that is at the forefront of our national politics, hasn't been debated in medicine for over a quarter-century.

Physicians also strongly oppose capital punishment. The American Board of Anesthesiologists has implemented a policy to revoke the certification of any anesthesiologist that administers a lethal injection. The AMA has long held that aiding in capital punishment proceedings violates the Hippocratic oath.

TIL: Though women are far more likely to suffer injury or death due to domestic violence, in heterosexual couples reporting spousal violence, 27% of the time the man struck the first blow, while 24% of the time it was the woman. The rest of the time, the violence was mutual in origin.

In general, about 80% of men in domestic violence studies exhibit diagnosable psychopathology, typically taking the form of personality disorders.

WILTIMS #151: Little of this, little of that

Yet another packed day. Three hours of dubiously useful lecture, a few hours of review for neuroscience, a kickball game and finally a documentary movie put on by the Ethics in Medicine Club. No rest for the wicked? Actually, a fellow movie watcher was jokingly annoyed with some other friends of ours for ditching the screening... to volunteer with sick children at a local hospital.

TIL: Epilepsy is a disease and seizures are symptoms. By a similar token, there are no treatments for epilepsy, only treatments for seizures. This may seem like silly semantics, but the serious point is that medications can temporarily alleviate the symptoms of epilepsy, but none effectively fight the underlying cause(s).

The organic causes of impotence can be summarised by a convenient, if unwieldy, acronym:

WILTIMS #150: Convocation of Thanks

Today was the Class of 2017's Convocation of Thanks. This is the day when we invite to our campus the families and friends of the donors who gave their bodies to our school as cadavers for gross anatomy lab. My classmates and I put together a program of musical performances, poetry readings, short speeches and the presentation of a painting all to present to our guests to display our gratitude, both to their loved ones for their selfless donation and to the family for following the deceased's wishes even if it meant delaying closure for nearly two years.

I was absolutely floored by the talent and consideration shown by everyone involved. Besides the dozens of presenters, the vast majority of our 200 person class showed up - a feat normally only managed for mandatory exams - on a Friday afternoon no less. At the end of the ceremony we adjourned outside to plant a small tree. It's funny that we hadn't noticed until this week that all the currently pink-blooming trees in front of our medical education building are actually tributes from previous years.

The most rewarding part of the day for me was talking with some of the family members after the ceremony. I was surprised at how focused their questions were for us. No one tried to keep a distance and talk about our experiences generally; they wanted to know if we remembered working on their husband/wife/mother/father. I feel like it was important to them, even though we all saw the cadavers equally at the time, that their specific loved one made an impact on our education - that their final gift had really made a difference to each of us personally.

I was selected as the final individual speaker of the day, a rather nerve-wracking honor made far more daunting when the musical tribute before me was absolutely phenomenal. Below are my remarks, including an ad-libbed opener to say what everyone was thinking: 

I feel sorry for the guy that has to follow them...

I'd like to start by sharing that I love stories. Romantic or dark, dramatic or adventurous, comedic or tragic - it doesn't matter. So long as there are characters being tested by challenges, I can't get enough. I think this was part of the draw for me to practice medicine, because there is no better field for stories. And we get them all: lifelong epics, sudden disasters, miracles, tragedies. Every patient has a story and it is our job to unravel it. One of the first things we learn in medical school is how to take a history - how to get the patient to tell you their story. But like a bad anthropologist, we try to help the people we study - to change how their stories will end. 

As is often quipped when you enter medical school, your first patient is already dead. But there is more to this saying than wit and morbid humor. These cadavers are not just an educational tool, a collection of organs and tissues, a body; these are people - people who have lived long, rich interesting lives - lives that have left their mark on their bodies. So even though the deceased could no longer tell us their stories directly, my classmates and I had the privilege of spending several months unravelling each story as told by the very bodies in which they experienced them.

I'd like to remind you that the vast majority of us had never seen a dead body before our first anatomy session at this school. That first incision was very hard, at least for me. My parents can be proud that they raised a child who, if nothing else, is uncomfortable cutting people with knives. At first to push through my discomfort, I think I objectified the person on my dissection table. She was an "it," not a "she" for the first couple weeks. I had enough on my mind trying to stay afloat through the deluge of information poured on us in those first days of medical school without trying to riddle out the metaphysics of death and identity.

Though it didn't happen all at once, my perspective did eventually change. Anatomical curiosities became possible symptoms. "These bones seem brittle" turned into "I wonder if she had osteoporosis?" Or "I wonder when he had that pacemaker put in?" "Do you think this fibroid tumor caused her any pain?" "I bet his heart anomaly gave every one of his doctors a scare! Maybe he had fun watching them freak out listening through a stethoscope before letting them know that they should be hearing a murmur." I think the ones that really got me were the tattoos and finger nail polish. These were some of the only clues to the personalities of our patients. By the end of gross anatomy, we wanted to know more about these people - not medically, not because we wanted to fix them, but because we had spent time with them and had glimpsed some of their story.

If I could thank our donors, who we honor today, I would thank them not just for helping future doctors unravel the tangled paths of the portal triad or brachial plexus, nor for giving hopeful surgeons practice with a scalpel. I would thank them for being our first patients, for teaching our first lessons in humanistic medicine, and for each of them sharing some of their life with us even after it had ended. 

TIL: Trophic factors act like a dead man's switch to neurons. A dead man's switch is a common trope in action movies where the bad guy rigs an explosive to detonate, not when they press the button, but when they release it. So as long as the button is held (and the bad guy is alive) the bomb won't go off.

Neurons normally receive constant input from chemicals called trophic factors. These factors do many things but one important role is to keep the cell from producing suicidal proteins. If you cut off the flow of trophic factors, by for instance severing the nerve's axon, the cell is no longer prevented from imploding, and often does just that.

WILTIMS #149: Psychiatric sci-fi

After the last couple behavioral science clinical conferences, I came to the conclusion that psychiatrists have to have an amazing imagination. In order to get a delusional or hallucinating patient to divulge their psychoses, you have to put them at ease. If you look at them like they're crazy when they talk about hearing voices, they'll close up and not talk about them anymore. You have to be totally at ease with even the craziest things that your patient says, so that they feel safe discussing things that they likely know most people don't understand.

The best psychiatrists have to be able to nod sympathetically when they hear about alien observers, ESP powers, and NSA conspiracies (admittedly that last one is more plausible nowadays than it was in the near past). I feel like sci-fi nerds could have the biggest advantage here.

Question of the Day: Is it ethical to treat a patient on death row for a psychiatric disorder that prevents them from being executed? You cannot be executed if you don't understand that you will die and that your death is the result of a judgement made against you for your actions. So helping someone reach that realization effectively condemns them.

TIL: Psychologists have a 5 year waiting period before they can begin romantic relations with a former patient.

Trichotillomania is the pathological pulling out of one's own hair.

WILTIMS #148: HM who?

TIL: HM, later revealed as Henry Molaison, was a famous patient who was studied extensively because of the memory loss loss that occurred as a result of radical treatment for grand mal seizures. The medial temporal lobes of both sides of his brain were resected in order to stop the extremely debilitating seizures. The loss of these regions of the brain resulted in a very interesting form of amnesia. HM lost the ability to form new long term declarative memories. He still had short term memory, procedural memory and the long term memories from before the surgery.

This all meant that if you had talked to him, he wouldn't have remembered the surgery or anything after it, but could form muscle memory from repeated trained tasks and could quickly solve puzzles that he had done repeatedly even though to him he had never seen them before. One of the other interesting quirks is that he always thought he was the age from the time of the surgery and would get very confused at seeing current pictures of himself.

WILTIMS #147: XP Mama Bear

After yesterday's neuro exam, I am really looking forward to a couple test-less weeks before the epic finale to this first year madness. By my count there will only be ~13 more WILTIMS posts for the year and then I will try to continue through the summer with weekly topical posts about whatever strikes my fancy.

This evening there was a talk by a guest speaker who is the mother of a young woman with the very rare disorder called xeroderma pigmentosum that I actually wrote about waaaay back at the beginning of the previous block. To sum up, it's a disease resulting from a specific faulty DNA mutation repair mechanism that results in horrible third degree burns at even the slightest exposure to UV light. Parents of these kids are often reported to child protective services because it looks as though they must have purposely burn their babies.

In developed countries, diagnosed children must become essentially nocturnal and take extreme precautions to travel during the day (e.g. being sealed in a sleeping bag to ride as a passenger in a car). In less affluent regions, these children often are not able to live this protected life and just develop and die from numerous skin cancers at a very young age.

Our speaker today started a summer camp for kids with this disease where the activities are either indoor or take place at night in a safe setting. There is nothing more heartwarming than giving kids with disabilities the opportunity to play and act like "normal" kids. Her daughter, now in her 20s but still slowly deteriorating healthwise, is the subject of this now 13 year old article in the New York Times. It's long but worth the read.

Hearing her mother talk about the confusion and frustration post-diagnosis and then her determination to build a community and find a way to survive, reminded me of my parents and their counterparts that were part of the founders of the foundation for our familial rare disease. There were a lot of similarities, actually, and I'm excited that a few of my classmates can now better understand the struggles of their future patients with rare diseases. 

TIL: The three reasons that you can commit someone to a psychiatric ward are:
     1. They are an imminent threat to them self
     2. They are an imminent threat to others
     3. They are unable to take care of their basic needs

Clerambault syndrome is when someone thinks a famous person is in love with them (and that is a ridiculous claim (George Clooney's fiancé does not have Clerambault)).

Capgras syndrome is when someone believes a loved one had been replaced by a different but identically looking person.

WILTIMS #146: Not alone

One of the most rewarding feelings is to have your faith in humanity reaffirmed. I spent most of my day trying to convince people to take a break from the incessant studying to play an already scheduled kickball game for which they had all voluntarily signed up. Between wrangling my team and trying to convince the other team's captain not to postpone the game, I was emotionally exhausted. Who knew that it's unheard of for medical students to take an hour break from studying three days before one of our seemingly omnipresent exams?

When it all came to nothing and we canceled the game, I went to study as far away from other people as I could get. Times like this I go to the abandoned cafeteria in an old office building that our school recently acquired. The room has big windows and is creepily empty in a post-zombie-apocalypse sort of way - in other words, perfect. Then while listening to music through my headphones, I hear another muffled melody break through during a pause in my playlist.

Another student had, without knowing I was there, started playing songs on the disused mini-grand piano in the corner. I paused my music and listened, quietly singing to myself when he played a song I knew. When he had finished and got up to leave, he noticed me and came over to apologize for disturbing my studying. I told him not to and we talked for a bit about the building, the upcoming exam, and the importance of balancing school with everything else that makes life enjoyable. It's funny that the times I most need reassurance that I picked the right species to try to save, inevitably someone sane comes along to remind me of just that.

TIL: MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) is a synthetic compound that was used for a while as an illicit drug because it caused heroin-like effects. That stopped however after 1984 with a rash of ER visits from users of the drug, which was causing a very familiar cluster of neurological deficits. It turns out this compound causes a form of Parkinson's disease by crossing the blood brain barrier, degrading to a toxin and destroying the cells of the substantia nigra. This region of the brain produces all of the dopamine for the brain and it's destruction results in the characteristic tremors and other associated symptoms. This is actually one of the few known causes of Parkinson's, as most cases are idiopathic.

WILTIMS #145: Music minor for the win!

Dissociative fugue is the coolest term I've yet to hear in behavioral science. It references the musical element, also called a fugue, where a tune is played by one instrument or orchestral section and then begun again by other instruments but changed slightly. Though technically a canon, a good similar example is "Row Row Row Your Boat", where each part jumps in on top of the one before it. The video above shows a beautiful visual representation of a fugue of Bach's. Pay attention to the colored melodic shapes at teh top to see how each line plays over the last.

The behavioral term of fugue creates a beautiful metaphor with frightening implications. With this disorder, a person experiences amnesia, forgetting the life they had previously led and starting anew even though the memories of the old life are still there in the subconscious (sound familiar?). Then at some point they revert back to the previous life and typically forget the new one. Each life led is slightly different than the previous and separated by time, just like the melodies of a musical fugue.

TIL: ADD was renamed ADHD (attention deficit hyperactivity disorder) in 1987. Why do I even know the term ADD, given I was born the same year it was invalidated?! In my own experience I feel like the switch only happened maybe 10 years ago, not 25+. It just goes to show how slowly information disseminates among both stubborn medical professionals and the public at large.

ADHD is not simply inattention, but a loss of self-control in general. Kids with this disorder will also have problems with planning and delaying gratification.

Persons with dissociative identity disorder (formerly multiple personality disorder) can experience a sort of auditory hallucination but they recognize that the voices are in their heads not separate from them as in schizophrenia.

WILTIMS #144: Stories to come

It's frustrating because I don't have much to show for the work I did today. I promise that I spent most of my afternoon writing and that at some point I will get to share that text with you, but not today. So I leave you with a couple neuroanatomy curios and hope to have a more post-worthy day tomorrow.

TIL: The anteriormost portion of the connection between the bulk of the brain with the brainstem, itself called the cerebral peduncles, is known as the crus cerebri. This tract contains the motor fibers that connect the motor cortices, which enable conscious awareness and planning of movement, with the spinal cord, that relays those commands, and the cerebellum, that does all the unconscious dirty work of keeping you balanced and coordinated. (all of this is super simplified)

The muscles of the face and head that can be controlled independently on one side receive innervation primarily from contralateral axons (nerves from the opposite side of the head). Such muscles include the tongue and lower facial muscles. Muscles that can only my stimulated bilaterally, such as the larynx, pharynx, palate and upper facial muscles are generally innervated bilaterally (from both sides). These rules are not very well conserved, as evidenced by weird folks (like myself) that can independently wiggle their ears.