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.

Study Aid #4

My stab at drawing all the muscles of the back in one diagram (not recommended). Simple, yes?

WILTIMS #43: Eeeeeeeeeeeee!

There's not much to report from today as we only has two lab sessions (one in histology, one in anatomy). The highlight of which was the "degloving" of a hand, to gain access to the ligaments, nerves and blood vessels beneath. Not an easy or cringe-less process, to be sure.

TIL: Never give a vasoconstrictor with local anesthesia in the fingers. Vasoconstrictors are drugs that cause the tightening of blood vessels and they are often given with local anesthesia to help them stay in the patient's blood circulation longer. The problem with the fingers is that they only get blood and nutrients from two tiny vessels and the administration of a vasoconstrictor will cut off blood to the entire finger. If not corrected quickly, the tissue will die and the patient could lose the finger.

Mini-Me and Dr. Evil

Muscles that control the pinky finger are named the digiti minimi, good words to know for when you're stuck with all those "I"s in Scrabble. Relatedly, the writers of Austin Powers 2 were either breathtakingly witty, or fantastically lucky with their choice of character names. Dr. Evil's half-scale clone is called Mini-Me. Though you might think this is merely a play on "Miniature Me," note that a minimi is a Belgian machine gun and that the extensor digiti minimi muscle is responsible for the iconic gesture seen in the accompanying picture.

The last tidbit that I learned today, came from a family member who had a recent brush with the medical field. A laminectomy, the removal of some or all of the back-most (or laminar) surface of one or more vertebrae, can be an effective late stage treatment for spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord. Fascinating if unpleasant stuff. Get well soon!

WILTIMS #42: A blessed nerve injury

At one point today, our head anatomy professor was up on a table on all fours with oven mitts on his hands and feet. Learning anatomical development is weird.

There was a fun point today where for the first time I learned something that someone had asked me about in the past few years of pre-med purgatory. They had a bump on their wrist and came to me because I was "the medical person" and I had no idea what it was. We made a solid guess based off some internet perusing and forgot about it. Today we covered synovial cysts of the wrist, one of which was in fact the cause of my friend's bump. It's a totally benign condition that can be resolved by, no joke, smacking the wrist really hard to pop the cyst.

TIL: The "anatomical snuff box" (pictured on the upper right on the beautiful hand of yours truly) is a groove on the forearm that received its name by victorian era snuff sniffers who found it a convenient to spot to place snuff while they put away their snuff box.

Injuries to the radial nerve can cause the arm and wrist to assume what's called the "waiter's tip position" (seen on the left).

A median nerve injury can be identified by asking the patient to try to make a fist and then looking for the "hand of benediction" (No, JPII didn't have a nerve injury; he is doing the namesake sign of benediction that happens to perfectly mimic the nerve condition).

WILTIMS #41: Uno!

We started today being bombarded with the intricacies of the arm and forearm. For some semantic reason we are calling the upper arm simply the arm. This made for some confusing statements such as, "The median and ulnar nerves don't innervate anything in the arm; instead, they travel all the way through the arm and innervate the muscles of the forearm."

We had to change into our white coats and professional attire for the second half of the day as we had the privilege of watching a sample patient interview by one of our professors of an actual patient. The patient was a kick in the pants and even though we were packed like sweaty alabaster sardines, we really enjoyed the lecture. Afterwards we broke up into smaller groups in the modular rooms upstairs to discuss the process of interviewing patients, specifically in regard to showing empathy.

I had a nice pair of experiences that I think beautifully show both my inexperience and potential. We were asked what we would say to a patient who we had just informed that she had mononucleosis. My first response was,

What's mononucleosis!? I feel like I know this... Is it a cancer? What has one nucleus? Who let me into this school anyway?

Meanwhile, one of my classmates responds by saying that she'd ask about the patient's medical history and try to find out where she contracted it from. I'm still beating myself up:

How does everyone else know what this is!? We don't take pathology until next year!

Then a second classmate takes a stab at it, saying that he'd want to find out what treatments are available and relay that to the patient since mono is treatable.

MONO!? How did I not know that mononucleosis is the full name for mono! Of course this disease isn't named the equivalent of "uno."

Hey wait, I know the answer to this and it nothing to do with the disease!

"Anyone else?" my professor asked, clearly frustrated at the direction my fellow classmates had headed with the question.

I raise my hand. "Well, I think I would first try to reassure her that..."

"THANK YOU!" The professor abruptly cuts me off. "Reassurance is exactly the word I was going for." She goes on to explain how to best reassure patients after giving hard diagnoses, while I start to feel better about my mono mental lapse.

TIL: In the loosely transcribed words of our example patient: "There are only two people you don't lie to - your doctor and your priest... and your mom!" Noted.

WILTIMS #40: Confidence, Schlemm and gravity

I forgot to mention yesterday that I poked around the hospital for the first time like a total dork. I wanted to try out the Au Bon Pain café in the hospital because I'm hosting an interviewee this Sunday and it's one of the few walkable dinner options I can offer (and I was tired and lazy - don't judge). After eating my surprisingly tasty sandwich, I decided to see how far my student ID badge would get me and explore the hospital a bit. As with any place that you probably shouldn't be, the key to exploring is to do it with blind confidence.

"Yes, I meant to go down this abandoned hallway! I'm inspecting the... uh, light switches. Yep we're all good here!" [walks hastily back the way he came]

Hopefully by the time I actually need to be in this hospital, I will be a smidge less lost than some of my classmates.

TIL: The canal of Schlemm is fun to say. I'm going to put it in the same category as the epiploic foramen of Winslow and the ampulla of Vater. Besides reveling in its euphonious name, I also learned it's location and function (apparently I learned the word euphony as well).

Schlemm's canal is essentially a drainage duct for the aqueous humor (gooey stuff) in the eye. If the eye is damaged and scar tissue ends up in the fluid, that tissue can collect in and block the canal, leading to an elevated intraocular pressure which is the most important precursor for the development of glaucoma. For anyone who's ever been to an optometrist, this is what they are checking for when they blow that puff of air at your eyes.

Our random sports fact for the day: when you see male gymnasts in the Olympics doing the Iron Cross skill (pictured on the right), the one muscle in their amazingly cut torso/upper extremities that they aren't using is the deltoid. The deltoid is used to abduct the arm (move it away from the torso), but gravity is doing all that work for the gymnast. He is in fact using all the muscles that normally oppose the motion of the deltoid (such as the trapezius and latissimus dorsi) while the deltoid, though bunched up from the position of the arms, lazily sits there waiting for gravity to stop stealing its thunder. Stupid gravity.

WILTIMS #39: Thymic elegance

Ouch. That test hurt. But the 5-exam week of hell is over! Huzzah!

There is something I wanted to share with you guys that I didn't learn today, but was really impressed with while studying. The thymus is a primary lymphoid tissue, meaning it's a site for blood cell development. Specifically, the thymus is responsible for the maturation of T-lymphocytes. You may remember from your high school biology class (it's ok if you don't) that there are "helper" T-cells and "killer" T-cells. These cells are part of the body's adaptive immune system, which recognizes a threat (from bacteria/viruses/fungi) and both attacks it and remembers it for future reference.

The nifty part is that the discerning thymus essentially weeds out both the lazy and homicidal T-cells before releasing the mature, level-headed ones into the body. It does this in two steps: First, it offers up some practice targets that it would like the T-cells to latch onto. If the cells don't bite, they're killed off. The survivors are then released to the second test area. The thymus again offers up targets, but there's a catch: this time the targets are actually pieces of good structures from within the body. If the T-cells go for these, then they are showing autoimmune capabilities and are also killed. This way only the cells that reliably target antigens are allowed to patrol the body. Elegant huh?

I could not for the life of me find a good diagram of this process, so I whipped this up for you:

TIL: Fascia adherens is found in the intercalated discs of cardiac muscle. This was on my first test today and I had completely forgotten it. Luckily, after looking it up during lunch, I got a different question about it right on test number two.