WILTIMS #121: Left at Albuquerque

TIL: As per the Director of Undergraduate Medical Education in Psychiatry, "NOS means we don't know what the hell it is." More specifically, NOS stands for "not otherwise specified."

When choosing an initial pharmacological treatment for psychotic disorders you don't choose based on the drugs' respective efficacy but by the side effect profile of the patient. In other words, most of the drugs work equally as well so worrying about the potential side effects is more important.

The third ventricle of the brain is bordered laterally by the thalamus and hypothalamus, anteriorly by the lamina terminalis and anterior commissure, posteriorly by the pineal body and posterior commissure, superiorly by the fornix and coroid plexus, and inferiorly by the optic chiasm, pituitary infundibulum, tuber cinereum, and additional hypothalamus.

WILTIMS #120: They did what now?

A page from "The Anatomical Basis of
Medical Practice" (red added by me)

One of the fun quirks of the neuro block is that we get frequent guest lectures by neurosurgeons. This is a rarefied group of lecturers than solicit the attention of medical students faster than a drill sergeant at basic training. They are psychotically confident, they always have the most ridiculous videos, and they only present the positive-outcome cases so they seem like heroes. That said, after watching them in the neurosurgery conferences a few times, I think being half an auditorium away is probably the best distance.

TIL: An anatomy book was released in 1971 that used Playboy-style pictures of women to show surface anatomy. It was so offensive that I honestly could have believed that our chancellor was just messing with us. The authors were doctors at Duke that wanted to make anatomy more approachable... and since most med students at the time were men they thought misogynistic writing and salacious pictures would be an improvement. Thankfully it did not get a second printing.

WILTIMS #119: Penny for your thoughts

TIL: Stereognosis is the ability to perceive a three dimensional object by touch, without the aid of the other senses.

Postage stamps in England do not specify what country they are from. This may seem like an unusual fact to pick up in medical school but, as usual for our history of medicine lectures, it was in service of a larger and more pertinent point. The topic of stamps came up while examining a stampless letter from 1840s Mississippi. The letter was a bill for services done by a doctor for the property of a plantation owner.

Our chancellor has taken pains to avoid teaching only the history of the white male heroes of medicine. Some of this profession's history is less heroic than we'd like to remember, and we should try to learn from the failings of our past to minimize their inevitable repetition in the future. The example at hand was of the role doctors played in the slave trade and slavery in the American South. It is an example of the phrase made famous by Hannah Arendt when describing lower level Nazi administrators: the banality of evil. The majority of evil done in the world is not done by sociopathic masterminds, but by normal people just doing their job and perpetuating the status quo.

But what can a doctor do to protest? We have (or will have) taken an oath to treat the sick. To refuse to work for slaveholders is to damn the slaves to pain and death, but keeping the slaves healthy allows the system to continue. How is this relevant to us today? Doctors stand on the sidelines of every football game, giving players and fans a sense of security that everyone will be ok, because there are medical staff around. But studies keep showing that football does irreparable damage to nearly everyone who plays. Is the medical profession allowing an unethically dangerous activity to go on out of tradition?*

I welcome your thoughts! Feel free to comment below.

*I have a rebuttal to the argument that football is a choice, but don't feel like getting into it tonight, but comment and I will.

WILTIMS #118: Olive anyone?

What do pyramids and olives have in common? They are both the actual anatomical terms for features of the medullary region of the brain stem. There was a good 30 seconds that I thought our professor was just messing with us regarding the "olives."

TIL: Schizophrenia sucks. I kinda figured this already, but now I'm more confident. Not knowing what is real or only in your mind would be truly maddening.

The two hemispheres of the brain are connected in four places: the anterior commissure, the corpus callosum, the commissure of fornix and the posterior commissure.

The tectum of the mesencephalon (midbrain) is also known as the quadrigeminal plate. Quadri- for 4 and -geminal for twins, which discribes the two pairs of lumps featured on its surface.

WILTIMS #117: When life give you dilemmas, make dilemonade!

Today we had 3 hours of neuro, two hours of FCM and two hours of medical ethics. Ethics was definitely the highlight. We had wonderful, intelligent and lively discussions on a whole array of ethical subjects. Throughout the course each student had to take a turn leading the small group through a case study. Today was my day and the topic was fascinating.

I discussed the surprisingly common practice of medical students performing unconsented pelvic exams on anesthetized hysterectomy patients. We discussed the many ways this could be considered unethical, even under the implicit consent of being treated in a teaching hospital. I then brought up other similar scenarios to see if there were situations where unconsented med student involvement could be ethical. If it was an exam of an ear instead of a vagina, people's feelings were more mixed. In another example, we mostly agreed that if a once-in-a-lifetime opportunity to observe a finding unexpectedly presented itself after the patient had already been knocked out, then bringing more people into the room than was consented would be ethical because the benefit to the education of students (and the future good of their patients) would trump the patient's rights, though the situation would have to be explained to the patient afterward. But that the students would merely be observing was a key point in this case.

The SNARE complex: Botox attacks the
BoNT sites while Tetanus targets TeNT

TIL: Botox, short for botulinum toxin, paralyzes muscles by cleaving the SNARE complexes that are responsible for binding of neurotransmitter-containing synaptic vesicles to the synaptic cleft.

Tetanus toxin works similarly but is only effective on inhibitory synapses. When these are deactivated, muscles are allowed to contract continuously. This is why tetanus is also known as lockjaw; early tetanus infection can cause people to uncontrollably clench their jaw. If left untreated, a common outcome is a broken back from all the back muscles contracting simultaneously. Get your tetanus booster shots!

WILTIMS #116: Cheers!

Today was rather mellow since I was in the lucky quarter of the class that had no lab or clinical session this afternoon. So, to supplement my musings for today, I have a couple of overflow points from yesterday's post.

Yesterday I went out with members of the Policy and a Pint club. As the name implies, this is a group that goes out to a local pub and discusses medical policy. The topic yesterday was single-payer and socialized medicine as compared to the US health care system, pre- and post-Obamacare. It was a smallish group this week, but we even had a resident Canadian to weight in. It is one of the highlights of attending medical school that I am surrounded with intelligent, concerned citizens who can respectfully discuss contentious issues and choose to do so at their leisure. Also, free beer.

Secondly, yesterday's topic in History of Medicine was on the role of the marginalized in medical education. Though I presented lots of fun tidbits, I never really broached the bigger point. In all of history, the ability for medical students to learn has been reliant on the bodies of the poor, lower class and subservient peoples. Gladiators were the subjects of Galen; murderers were the cadavers of Harvey; slaves were bought on their deathbeds for dissection in early southern medical schools.

Though we'd like to think that this trend ended alongside the slavery and indentured servitude that enabled it, that would be wishful thinking. My medical school has two major teaching hospitals, a large private hospital in the suburbs and a large urban public one in the city. As is common all over the country, teaching opportunities are fewer in the affluent and correspondingly litigious private hospitals. Thus the best learning experiences are often found at the grimy public hospitals, where the patients are overwhelmingly poor and of minority ethnicities. We still exploit the exploitable in order to learn and we have a ways to go before we fix this inequality.

TIL: If you use the phrases "touch yourself" and "make it rigid" in any context, you will overwhelm even the best resistance to juvenile humor.

You cannot have a diagnosis without impairment. Hearing voices is not a disease unless it causes dis-ease.

WILTIMS #115: The triumphant return

Against all odds, I have survived the second block of medical school! Whereas that block was supposed to be the hardest of first year, this next one is supposed to contain the hardest individual class: neuroscience. Fear for my worn out brain aside, I'm excited to get back into the anatomy lab to look at some other brains.

TIL: For hundreds of years, medical students had to rob graves in order to have bodies to dissect. They were called resurrectionists and would go out on - I kid you not - dark and stormy nights in the fall when the ground is still moist and easier to dig. Creepy Halloween story much? Kids were even warned about the "night doctor" who would snatch them off the street to dissect them if they weren't home on time.

In 1788, medical students from Columbia were confronted by an angry mob for dissecting a white woman. The color and gender is important, because no one had a problem with people dissecting black slaves or white male murderers. The governor called in the local militia to protect the anatomists but they wouldn't fight their fellow New Yorkers, so the upstate militia was called in. This was the first major riot in the fledgling United States.

The oldest medical building in the US at the University at Maryland and is built like a labyrinth to keep riot mobs from easily finding the anatomy lab.

In 1989, the University of Georgia started renovating its old medical school building and had to have the anthropology department excavate the bones of dozens of stolen dissection bodies from the dirt floor of the basement.

The Wellcome Museum of Anatomy and Pathology in London is only open to physicians and medical students (and other allied health professionals).