WILTIMS #498: O.o

TIL: Parinaud's syndrome is a weird collection of neurological eye exam findings usually caused by a tumor in the pineal or midbrain regions of the brain. The most prominent symptom is the inability to look up. The eyes can still move up, but the patient can't look up voluntarily. This can be demonstrated with a "doll's head test" where you have the patient relax looking straight ahead when you suddenly rotate their head forward. Another part of the brain controls this reflex, so the eyes will roll up in their sockets just like a doll's, before reverting. If one of the eyes is more affected than the other, then the patient may have double vision from one eye being stuck lower than the other.

Image from here

The next sign of Parinaud's has a fun name: pseudo-Argyll Robertson pupils. This is when the pupils are dilated (the black of the eyes is larger than normal) and they won't constrict when you point light at them. You can still make them constrict though if you use a trick. When you look way off in the distance, your pupils dilate a little; when you look at an object really close to your face (like your nose), the pupils constrict a bit. This reflex should be preserved in patients with Parinaud's syndrome. Again, if one eye is more affected than the other then the pupils may be different sizes at rest.

Then we have a whole bunch of related problems with moving the eyes in unison. These patients have a problem when you have them rapidly look at an object close or far away from them. Normally, you want both eyes to move in unison and stop at the precise spot to properly focus on an object. When that doesn't happen (e.g. one eye moves faster than the other, or overshoots the target, or stutters to the spot rather than moving smoothly), the patient will experience temporary double vision. Often these patients will have a particularly weird problem called convergence retraction nystagmus, where the eyes will retract into the socket when you have them look at their nose. This is because the ocular nerve is getting confused and instead of using some of the eye muscles to look in a direction, it contracts all of them. This pulls the eyes inward. See the GIF for an example!

Image from here

Lastly we have Collier's sign, marked by bilateral upper eyelid retraction. This makes the patient look a little "bug-eyed," but specifically results in an uneven amount of white above the irises. For an example, take a gander at this fantastically mustachioed man on the left. He has white visible above the irises of the eyes; for comparison, see that neither of the persons pictured above have white visible there. If patients with Collier's sign could look up (which they usually can't, as per exam finding #1, above) the eyelid would match the movement of the pupil and recede even further up.

WILTIMS #469-73: The Great Restart

Last week I started a quick two-week rotation in pulmonology, the study and treatment of lung and other respiratory disorders. I had particular interest in this elective because, as I've mentioned before, I'm thinking about someday practicing as an intensive care doctor. Though I'm leaning toward pediatric critical care at the moment, if I should choose the adult route, many adult critical care doctors are actually double trained in pulmonology and critical care (or "pulm-crit" for short). This is historically due to the close correlation of lung problems with critically ill patients; many ICU patients are on ventilators that breath for them while they're in the unit.

Monday: On my first day with the pulmonology consult team, some cosmic karma balance was achieved as I had the privilege of apologizing for the terrible communication and bedside manner from a surgery team. They apparently cancelled a surgery after the patient was already under general anesthesia for a complication that could have been easily foreseen days before. Then they didn't tell the patient or family what happened or what the next steps were. It just takes a little communication, folks!

MondayIL: Ground glass opacities on CT scan can be misleading. This term means that the there are areas of light and dark patches making up the lung tissue. The question is: which is the healthy tissue and which is diseased? By tinkering with the image settings you can make the light or dark look normal, so radiologists have to use special tools to compare the lung tissue with known brightnesses in the image, letting us know which it is. We can also make educated guesses based on the condition(s) we're suspecting.

TuIL: What a bronchoscopy procedure looks like. I had heard about this sort of colonoscopy of the lungs, but hadn't seen one performed yet. Having seen many colonoscopies and endoscopies while volunteering before med school, the process is very similar. The only catch, of course, is that instead of exploring a solitary tube, you are exploring an incredibly complicated tree. Also, with the GI tract, you can inflate it with air to help you see, but the lung pipes are not nearly as expandable, so you run out of room and visibility very quickly. Want to rinse something with water? No problem in the bowel but, in the lungs, you are literally drowning the patient so you have to suction the fluid back out immediately.

WIL: There is a super rare condition called Erdheim-Chester disease that has only been reported in less than 500 individuals. Odds are the patient we are consulting on is the only one with this disease I will ever see in my career. It has many diverse manifestations, but for my pulm team, we are most concerned with the devastating cystic lung dysfunction that is seen in these patients. Unlike in emphysema, where the tiny bubbles of the lung stretch outward like bubble gum blown too big, cysts have thick capsules that keep them from popping. When your whole lung slowly turns to these thick balloons of useless tissue, it makes breathing rather difficult.

Thursday: This was a weird morning because we waded into an ethical quagmire due to some dubiously informed consent. We wanted to try 'scoping a man who the anesthesiologist considered a very high risk patient. The problem was that the patient didn't seem to grasp that there was a small, but non-zero risk of needing to be intubated (put on a breathing tube) if his vital signs deteriorated. He wanted the procedure, but not the risk and you can't have it both ways.

We tried calling his family, but they were similarly indecisive. Meanwhile, Anesthesia recruited two more of their own to consult as to the risk to this patient. Our team was four people on its own. Nursing had at least two people in the conversation. For patient privacy reasons, we moved the mob to the still empty procedure room. After going back and forth about the risks and options for different levels of anesthesia and trying to justify why we were doing this case at all, it was decided to call the patient's primary doctor for this admission, the head of cardiac transplant surgery, who decided to join us for the discussion.

The man swaggered into the suite and basically dismissed everyone's concerns about both patient safety and consent. "The guy's heart is failing; of course it's risky. So is anything on this guy." He then wandered over to the patient's bedside and asked, "You want the procedure, right? Good. Let's just get this done." So we did. The patient got very limited sedation (because anesthesia wasn't comfortable giving him anything that might jeopardize his cardiac function) and was coughing and gagging the entire time we had a tube down his throat. We got our samples. The patient didn't remember a moment of the half-hour I was restraining his hand from pulling out the tube in his lungs. He woke back up with no ill effects.

I still don't think we should have done the procedure. The patient consented wholeheartedly by the time we went (even though he still didn't want a breathing tube), but he explicitly said that it was because he wanted to eat after a whole night of being NPO (nothing by mouth). There was a lot of gray area in every aspect of this event and, if the patient's life is not on the line, it probably makes sense to take a step back and reschedule the procedure for the next day, once we can be more clear about the risks and the patient's understanding thereof.

ThIL: Jugular venous distension is a very specific physical exam finding but not very sensitive, because the anatomical distances we use are severely underestimated.

FIL: Tree-in-bud opacities are a radiographic finding on CT imaging that looks... like a budding tree. It can represent many different pathologies, but generally means there is something filling up the deepest airways of the lungs.

From: http://pubs.rsna.org/doi/full/10.1148/rg.253045115

WILTIMS #432-434: Untz untz untz... oh, not that kind of clubbing

MondayIL: Homans sign is a physical exam maneuver used to test for deep vein thrombosis (DVT). To perform it, you have the patient rest on their back while you support their knee. You then abruptly flex their ankle. If this elicits discomfort, it is positive for... actually probably nothing. This sign is a terrible predictor of DVT and may even be dangerous to perform. Don't use this test.

Every once in a while I learn something that I realize I should have learned ages ago. Unfortunately I usually learn these facts in an awkwardly public setting like in front of attending or patient. Today's example is about clubbing. Clubbing is when the tips of one's fingers swell and the fingernails curve (making the fingers look like little clubs, hence "clubbing"). I therefore thought that dramatically curved fingernails were indicative of early-stage clubbing. Nope. Not a thing. People can just have curved nails.

The way you actually tell if there is clubbing is by looking at the angle made by the tip of the nail, the root of the nail and the first knuckle. If it is concave, it's normal. If it's flat then there is mild clubbing. If its convex (the nail bed bends out between the knuckle and nail tip) then there is severe clubbing. We still don't know what causes clubbing, just that it is correlated with a whole bunch of serious disease processes.

TuesdayIL: Gadolinium contrast (the stuff used in MRIs to make body-stuff more visible) is cleared from the blood much more slowly in patients with chronic kidney disease. This can cause nephrogenic systemic fibrosis, a disease that sounds really vague, but is actually only caused by gadolinium exposure.

Autosomal dominant polycystic kidney disease (ADPKD) is caused by a defective APOL1 gene. This allele is very prevalent in the black population, much like the sickle cell allele, and it's thought that this parallel is due to a similar reasons. Whereas sickle cell heterozygotes (people who only have one copy of the defective gene) are thought to be protected from malaria, APOL1 seems to protect from a different parasitic disease called trypanosomiasis.

We have no good treatment for ADPKD. We can essentially use dialysis to bide time until a kidney transplant can be done. An interesting issue can arise when a family member wants to donate a kidney. Since the disease is inherited, there is a not-insignificant chance that the family member also has ADPKD and will need their extra kidney for as long as it is healthy. So to attempt to donate, the family member needs to consent to finding out that not only can they no donate, but that they may be soon heading for the same fate.

WednesdayIL: Dementia can cause increased variations in an elderly patient's sleep cycle. There are normal age-related changes, such as going to bed earlier, waking up earlier, sleeping lighter, waking up more often, etc. Patients with dementia frequently have worse sleep disturbances including a shift away from the restful REM sleep.

WILTIMS #139: Hi, my name is Christopher and I have no idea what I'm doing...

Today was my first graded mock Objective Structured Clinical Examination (OSCE), and though less than ideally organised, it was actually a lot of fun! Part of the exam entails interviewing standardized patients. These incredibly experienced actors can portray a patient for both a history and physical exam. Today, we only did the history of present illness and a social/sexual history with these actors. We practiced physical exams on each other (presumably because we are too inexperienced to bother a standardized patient with our poorly aimed prodding).

The goal today was just to practice our communication skills in the setting of an actual fake medical exam room with an actual fake patient. It was nerveracking at first but went surprisingly well. The best part was debriefing with the actors not two minutes after they were so convincingly a totally different person. That I managed to comfortably talk to an actor about his fake chlamydia shows how far I've already come in the last year.

Unsurprising fact of the day: Coffee causes and relieves headaches, depending on the dosage.

TIL: Going to Wendy's is totally good for my medical education. Apparently a former student at my school went to the local Wendy's and discovered in the wall display about Dave, the founder of the burger chain, that he had a compensated fourth cranial nerve palsy. And he actually did!

The fourth cranial nerves (or trochlear nerves) control just one muscle in each eye. If one of these nerves fails, the corresponding eye will be rotated in the socket. To correct for this, a person with a fourth nerve palsy will cock their head slightly to level out the bad eye. The good eye can adjust to this angle, but you have to maintain your head in that position in order to avoid blurred vision.

Smoking is a potent comorbidity for brain aneurysms. Smoker aneurysms are more prevalent, they grow faster, they rupture more readily, and they do worse during surgery and recovery.

Projectile vomiting is not simply puke that travels in a parabolic arc. Projectile vomiting is usually caused by increased intracranial pressure and is characterized by being a surprise to both the patient and physician. There is no nausea and no retching - just sudden, explosive vomit.

Pituitary tumors can cause bitemporal hemianopsia (tunnel vision) and diplopia (double vision), by disrupting the second and third cranial nerves, respectively.

WILTIMS #131: I'm droopy... or have a cranial nerve palsy

I thought we already covered cranial nerves in gross anatomy all those months ago. I was wrong. Oh so wrong. The 2½ hours of lecture this morning exclusively on cranial nerves and their associated spinal cord nuclei taught me that the hours spent in gross anatomy were just a friendly introduction to convoluted roadmap of neurons that control an enormous amount of the head and body from a scattered core of seemingly indistinguishable spinal cord chunks. An we still have several lectures to come on eyesight and the optic nerve (CNII).

This afternoon we had a fantastic lecture on the ethics of procreation and genetic testing by this guy. He managed to quickly and objectively sum up the arguments from everything from abortion to cloning to "designer children." One of the more interesting points was on the future of certain technologies and their impact on the long held ethical beliefs of all parties involved. How does the debate over abortion change one we create the artificial uterus? That's not ridiculous to think about considering how medical science has continued to push back the limits of premature viability and push forward in vitro early embryonic development.

TIL: One of the cranial nerve exams is to have the patient sick out his or her tongue. If it deviates to the right, either the upper motor neuron of the left hypoglossal nerve (CNXII) or the right lower motor neuron has been damaged.

Along the same theme, because the upper portion of the face is innervated by both sides of cranial nerve VII but the lower muscles of facial expression are innervated purely contralaterally (from the opposite side), if you have a left upper motor neuron lesion you will have a droopy lower right face, while a lower motor neuron lesion will result in a Bell's palsy (half face droopiness) in the ipsilateral side.

If one of the abducens nerves (CNVI) is damaged, it will result in double vision that resolves if the patient turns his or her head. The troclear nerve (CNIV) also causes double vision when damaged resulting in a short of twisting of the eye within the socket. Patients can cancel out the distortion by awkwardly tilting their heads.

"Brain birth" is a concept analogous to brain death accepted by some proponents of abortion rights that states that, just as adults who have been rendered irreparably unconscious are declared legally dead before their heart and lungs have stopped working, unborn fetuses should not be considered alive until the brain had developed enough to be meaningfully useful.

WILTIMS #53: Brains and lightsabers

Yesterday was a dramatic day that concluded months of waiting on a couple fronts.

First up was learning how to perform an HEENT (head, eye, ear, nose, throat) exam, which meant finally getting to use the most expensive single item we've had to buy for medical school: our ophthalmoscope/otoscope (eye/ear scope). The cost was particularly annoying because it's not obvious why we need to buy one of these devices in the first place, as they are provided in every exam room and hospital unit in the country. Now, we didn't need to buy the fanciest model, but it was part of a bundle with our blood pressure cuff, reflex hammer, tuning forks, etc, so I splurged. Anyways, it was nice to finally get to use some of this doctor-y stuff!

To examine the eye with an ophthalmoscope, you start out about a foot away from the patient and place your thumb above their eye (to reassure them that you won't smack them in the head with the scope as you move in). You then align the beam of light with the pupil by looking for the “red reflex” which is weirdly named as it is merely the light reflecting off the retina on the back of the eye. This same phenomenon causes red eye in photographs. After finding the red reflex you move closer to the eye, being sure to keep the light centered on the pupil. Once you get close enough, you can see the blood vessels in the back of the eye. In order to see the vessels clearly, you have to counteract the lens of the eye by focusing the lens in the scope. Interestingly, people with different glasses prescriptions will need a different focus setting on the ophthalmoscope.

In anatomy lab yesterday, we finally reached the apex of the class: cutting open the skull and removing the brain. The day before, we had removed the scalp, so we started by placing a rubber band around widest circumference of the skull to mark out our planned cut. We then took an electric oscillating circular saw and cut through the bulk of the skull, trying to leave a small part of the inner surface intact to protect the brain. Oscillating saws, rather than rotary saws are used to cut through bone and casts because they have a much harder time ripping through soft tissue. Next we used a rubber mallet and chisel to break the remainder of the bone and finally expose the brain.

One cool thing about the interior of the skull is that it has indentations in the bone from the blood vessels of the dura mater (outermost meninx). These meningeal layers are the last thing we had to remove to see the brain, which looked... exactly like you'd expect a brain to look. It felt rather rubbery and stiff as a result of the preservation process.

Literally 5 minutes after I was touching the brain of a dead person amidst the smell of burning bone and flesh, I was waiting at a bus stop to leave town for the weekend. More than anything I wanted to turn to the other bus-riders and shake my smelly hands at them yelling, “Brains!” I managed to hold back my impulse, but let this be a lesson to you - you never know if the guy next to you on the bus was touching brains five minutes prior.

WILTIMS #44: Embroidery saves the day?

Last night I hosted an applicant to our medical school who had an interview today. The whole experience just reminded me how happy I am to be past that stage - a needed reminder with another test looming.

My day started out with some Nobel Prize trivia following the announcement of this year's Prize in Medicine/Physiology (for vesicular cell trafficking incidentally). Our anatomy professor told us the complicated tale of Alexis Carrel, 1912 Nobel Laureate in Medicine. Carrel pioneered the first vascular repairs (sewing back together torn blood vessels), in part using the technique of embroiderers from the Lyon area of France.

The problem with suturing blood vessels up to that point was that the standard technique called for clamping off both sides of the vessel and then trying to stitch first the top and then the bottom of the now flattened vessels walls. The reason this didn't work is that vessel walls are incredibly thin and fragile. The clamps irrevocably damaged the tissue and the surgeons couldn't suture one side without nicking the other, causing even more damage. The answer came in the form of the triangulation stitch, a method borrowed from sewers (as in one that sews, not one that collects feces) of fine silk tubes. They would use three small stitches placed equidistant around the tube to pull the tube taut, forming three flat sew-able surfaces that, when relaxed, formed a complete circle.

This technique made many now common surgeries and the entire field of transplantation possible, saving countless live. So why did I sale Carrel's story was complicated? His best friend was Charles Lindbergh, the famous aviator and later Nazi sympathizer. Together they invented the first perfusion pump, the precursor to the artificial heart, again saving untold lives. However, they were both outspoken supporters of eugenics and Carrel later moved back to France during the German occupation of WWII to work in high level scientific positions in the Vichy government. Thus, these were men with murky legacies, to say the least.

TIL: A good way to find reflexes on a seemingly reflex-less patient is to ask them to lock their hands and pull against their own strength as hard as they can. While the patient is distracted, you can whack them with the hammer with renewed success.

WILTIMS #22: Quickie

Twas a long day with way too much information, but as it's already late, I'll just leave you with a couple quick items and fill you in more tomorrow.

TIL: The term hypochondriac actually quite literally means "pertaining to the upper third of the abdomen." This is from the greek roots of hypo- (under) and chondro- (cartilage) referring to the cartilaginous lower rib cage. The word has come to mean an excessive worry about one's health because physicians of antiquity attributed many ailments to that region of the abdomen. Over time hypochondria became a catch-all term to describe any unexplained conditions, and later to describe people with illnesses that no one can find evidence of.

The rectum actually drains blood via two totally separate venous blood tracts. This becomes important in regard to colorectal cancer, because if the tumor drains blood into the vena cava, metastases will show up in the lungs. If, however, the tumor drains to the portal vein, the metastases will primarily collect in the liver and only secondarily make it to the pulmonary capillaries.

The spot on the skin where one makes the incision for an appendectomy is called McBurney's point.

WILTIMS #16: ALL the stories!

The past two days were a whirlwind of activity, broken up by very little sleep. Yesterday began with histology lab and three histology lectures. Histo continues to cement itself in my mind as a nice time to take a nap and/or catch up on my social media - I'm looking at you Reddit (no, literally, I have Reddit open in my other tab).

Luckily, our anatomy lecture that afternoon was given by an incredibly entertaining radiologist that bribed us with candy (that never stops working, apparently). The talk was on the basics of reading x-rays and CTs, specifically in the thorax, as that's all the anatomy we are expected to know so far. One of our first exercises was to try to identify a structure from the three cross-sectional images below.

We tried to apply the skills we had just learned to make educated guesses. Looks like a tube. White is dense material; black is air. Deformed bone? Nope. Calcified vessel of some sort? Wouldn't be that thick... Messed-up kidney? Is "messed-up" a medical term?

I'll let you think about it. Clue: you all know this structure. Click here to see the answer.

We also discussed the common pathological findings of the anterior mediastinum, which are remembered by the dumbest mnemonic ever: the 4 Ts. These are thymoma, teratoma, thyroid, and terrible lymphoma. Does that last one seem like a bit of a stretch to you, too? Here the professor asked our class of ~200 to raise their hands if they knew someone who had had the most common lymphoma: Hodgkin's. (I raised my hand along with probably a quarter of the class). She then asked us to keep our hands up if they were immediate family. At this point I gesture to her that I had in fact had it myself. You could tell she was stoked that I was there to make her point. 

Dr. R: What's your name?

Me: Christopher

Dr. R: I don't want to violate HIPAA [class chuckles], so how about you share with the class.

[passes me the mic]

Me: Actually, I had Hodgkin's lymphoma.

Dr. R: And how are you doing?

Me: Pretty good.

Dr. R (to class): He looks pretty good to me.

Dr. R (to me): Would you call lymphoma "terrible?" [I tentatively shake my head] I mean I'm sure it wasn't fun and you probably called it many nasty things, but you survived, yes? [I nod]

Dr. R (to class): You see? Lymphoma, as far as cancers go, is very treatable and almost never terrible. This is why I hate that mnemonic.

Dr. R (to me): Here, take some candy and pass it down your row.

So cancer perk #56: Get's you candy for sharing in class!

After this we had smaller group sessions to go over the radiology. Our group was taught by the chief radiology resident from Westchester Medical Center, who was very nice and down to earth.

Then it was off to the grass in front of the pediatric trauma helipad for the first flag-football games of the season! The medical, public health, and physical therapy students field over a dozen teams each year for a weekly co-rec flag-football league.

I helped ref the first game with one of my roommates (please always be nice to volunteer refs in any sport) then took the field with people who I had mostly just met to battle it out. After a promising 12-12 halftime score, the other team got on a streak and eventually won 42-12. The game was not as lopsided as it would appear though, because any goal scored by a girl is double points and their girls were quite good. Lots of fun and a good study break.

My roommates and I made it back to the apartment at around 8. It was here that my day took a turn for the worse and I only have myself to blame. I (being stupid) decided to sign up as a scribe for the school's student run lecture transcription service. We type out notes from recorded audio tracks and are paid for our time. The only problem with this plan is that I can't type quickly - at all. It took me 6 hours to type and format a 35 minute lecture. Never again.

Today, we had another clinical skills session where we learned more of how to do a physical exam. To be clear, all we're really learning at the moment is how to look like we know how to do a physical exam. For instance, today we learned how to palpate (touch), percuss (tap), and auscultate (listen to) the neck, chest and back. Theoretically, this would enable us to examine the lungs and heart, but as we have no idea what normal or abnormal sounds like yet, we're really just playing doctor - albeit very accurately. A common, if disconcerting, motto for clinical learning is "Fake it 'til you make it."

In the afternoon, we had our last anatomy lab before our first test on Monday (both a written and practical). It turns out that our cadaver continues to be the best body in the room. Our person's heart had an interesting and surprisingly common birth defect, a patent foramen ovale. This is when there is a hole between the right and left atria of the heart. During fetal development, this shunt allows the oxygenated blood from the umbilical cord to skip the developing lungs and perfuse the rest of the growing body. Usually the shunt closes after birth, but in 30% of people a small hole persists into adulthood. As long as it's small enough not to dramatically affect the heart's circulation, the person would likely never even know until someone listens with a stethoscope (like we did this morning!) and hears the associated murmur (unlike we did this morning...).

TIL: A flail chest is when 3 or more ribs on one side of the chest are each broken in two or more places. This causes a portion of the chest to move in paradoxical motion. (Warning: The video is... unsettling)