Microbiology lab

Over the past few weeks, we have been spending some of our lecture hours in lab playing with bacteria. There are mixed opinions about the lab sessions among my classmates, but I enjoyed the labs overall.

Their purpose, really, was to have us perform experiments and observe the results to learn key concepts of bacterial morphology and development of resistance to antibiotics. That works out great for people like me who need a few modes of delivery for the material to sink in properly. Another up-side was that it cut us all some slack by decreasing the "information concentration" (volume of information per unit time).

I particularly enjoyed learning how to do a Gram stain, the archetypal protocol for distinguishing between Gram-positive bacteria (which have a thick cell wall and stain purple) and Gram-negative bacteria (which have a thin cell wall and stain red). Whether a bacterial is Gram-positive or Gram-negative is usually instructive as to which types of drugs it will likely be responsive to.


My favorite part of the lab was the experiment demonstrating how bacteria have developed resistance to antibiotics. The three plates above were all plated with Staphylococcus aureus, a particularly nasty bug that's responsible for skin (staph) infections, pneumonia, and a whole range of other problems. The plate on the left is a strain of Staph isolated from the community in 1945, the middle plate is a strain from 1965, and the plate on the right is a strain isolated in 1999. The little white disks each contain a different type of antibiotic, and you know that the bacteria are susceptible to a given antibiotic if there's a zone of clearance around a disk: the larger the zone of clearance, the more effective the antibiotic is at preventing bacterial growth or killing the bacteria.

Notice how every antibiotic was effective at clearing the 1945 version of Staph. aureus, but that effectiveness was markedly decreased against the 1965 strain. By the time you get to 1999, five of those eight antibiotics are completely useless against Staph. aureus. The doomsayers are worried about what happens when we don't have any antibiotics that are effective against highly resilient bacteria. As future doctors, we must be careful when prescribing antibiotics in order to delay the generation of new resistant strains.

A word on switching preceptors

Last semester, I found myself in the unfortunate position of not being satisfied with my preceptorship experience. We were semi-randomly matched to a physician, either associated with the University or out in the community, usually in a specialty that would afford us opportunities to practice general patient interaction skills and be exposed to a range of different patients (Family, OB/Gyn, Peds, Emergency, Internal).

I matched with a doctor practicing occupational medicine, which basically involves seeing patients who were injured on the job. There's also usually some sort of legal involvement: a lawsuit against the employer, requiring the doctor's signature to allow the patient to return to work, or something along those lines.

Being at the nexus of medicine and two arcane systems of law (Federal and State), there were many aspects of occupational medicine that I frankly found distasteful. First, in some circumstances, doctor-patient confidentiality does not exist. My preceptor sometimes had to preface a question by saying, "Now you don't have to answer this because my records are not confidential..." To me, taking away that privileged relationship between doctor and patient subtly shifts the role of the doctor away from first and foremost caring for the patient's health. The societal role that my old preceptor filled is a necessary one, but I didn't have any interest in spending the next two years of my preceptorship in that environment.

There were other consequences of being caught in middle of a tug-of-war between medicine and law. My old preceptor counseled some of his patients that they may be followed or videotaped by their employers who hope to prove that their injuries were not as severe as they claimed. Also, in order to determine how much worker's compensation should be given to a man with a rotator cuff injury, the deficit in the shoulder's range of motion was measured and applied to arbitrary guidelines imposed by the State and Federal governments. Again, I just didn't have any interest in gaining more exposure to that kind of medicine.

I feel it's important to emphasize that, personally, I very much liked my old preceptor. He seemed to enjoy his role as mentor, and I learned a lot from him. I felt bad telling him that I would no longer be coming in; it was like a break-up conversation. But at the end of the day, this is my medical education, and I need to do whatever is in my power to make the most out of it.

Finding a new preceptor

Finding a new preceptor on my own was a lot more difficult than I thought it would be. My strong preference was to work in the emergency room environment, but I kept an open mind to other possibilities, as well. After striking out with several promising leads, I began to grow discouraged about my prospects of finding a new preceptor.

Then, at the end of last semester, I attended a sonography workshop hosted through the Emergency Medicine Interest Group. Afterward, I approached the doctor who ran the workshop, explained that I was looking for a new preceptor, and asked if he knew if any of his colleagues might be interested. "I'll take you," he said, and that is how I met my new preceptor.

I feel very fortunate to be working with Dr. Browne.

Multi-tasking in medical school

The first test of the semester is done. But the higher-ups are testing our multi-tasking skills by throwing at us two concurrent courses: Disease and Defense (this morning's test), and Blood and Lymph. The first test for B&L is coming up this Thursday, which means that I won't be getting as much relaxation and decompression time as I would have liked for this weekend.

It's interesting to compare my classmates' different strategies for this juggling act. Some people focused intensely on preparing for today's D&D test and resigned themselves to falling behind in B&L. The lecture hall was very empty this week. Others managed to keep up to date on both courses even though it means that they didn't have as much time to cram for the D&D test.

I hate falling behind for many reasons and chose not to miss lecture this week. My compromise was that I just didn't spend as much time preparing for the lectures as I normally do. Because of that, and because my mind was drifting off into the land of antibiotics and bacterial toxins during lecture, I'm not sure if my compromise was necessarily any better than not going to lecture at all. We'll see if I'm brave (or foolish) enough to try that option the next time we have a double-header.

Crazy Saturday night in the ER

I went into the ER yesterday for my second preceptor session with Dr. Vaughn Browne. It started off rather slow in the afternoon but turned into quite the night.

There was the guy who came in with possible neck and intracranial injuries after he was hit repeatedly with a blunt object in a drunken fight. It took four security guards and a team of doctors just to keep this guy down, he was thrashing around so bad. "I'm a human being, not an animal!" The decision was finally made to intubate him (sedate him with assisted breathing) in order to protect his neck and head injuries. During all of this, I stood by as a passive observer, shocked.

Then there was the Pentacostal preacher who prophesied the night before that God would inflict him with pain so that his congregation would Believe. He came in with ambiguous chest and flank pain and brought with him half his congregation camped out in the waiting area. The whole work-up was done on him, just in case there was actually a medical basis for his pain, but I'm not sure how that turned out.

Learning how to insert an IV line

Toward the end of the night, I spent some time with Vicky, a nurse who taught me how to insert an IV line. After all of the passive observing I had done so far, I was eager to actually do something and to pick up a new skill. My first patient was a sweet old man who called himself a "professional patient." He was having a tough time of it with kidney problems. His veins were particularly difficult because of his chronic illness, but I was able to get the line in on my second try with minimal fumbling.

My last case of the night was a drunk driver who got in a minor accident that didn't involve anyone else. This guy was very, very drunk. "I'm not sure if this is the best person to practice on," I told Vicky, wary of him becoming belligerent and uncooperative in the middle of my novice attempt to stick him with an IV. Two security guards were in his room, and two more were hanging out outside in case he got out of control. "Come on, he's the perfect person for you to practice on!" Vicky replied with a twinkle in her eye.

At this point, the two security guards were arguing with the patient, trying to get him to lie down. "Watch this," Vicky whispered, "I'm gonna sweet talk him. I'll put on my mommy-face, and he's gonna give us his veins." Vicky has been doing this whole nursing thing for quite some time, and she's good. She calmed the man down in no time, introduced him to me, and before I knew it, I was this guy's best friend. Of course I could take some blood, no problem! In the middle of the procedure, my best friend started thrashing around. All four security guards descended on him, but I had already lost the vein. "That was his fault, not yours," Vicky reassured me. With security holding him down, I got it on the next try. Adrenaline was pumping when I left the room, and I didn't really calm down until I got home.

"Now try doing that in the back of a speeding ambulance."

Witnessing death

During my preceptor experience yesterday, I watched for the first time as someone died in front of me. A man in his mid-50's had a heart attack. He got CPR right away, even before the paramedics arrived at the scene, but he flat-lined soon after arriving at the ER 20-30 minutes later.

In these situations, the medical students are usually told to stand by in case the team needs CPR relief. This man didn't make it that far, though. I watched as the emergency team did their thing, trying my best not to get in the way. Then, before I knew it, the attending physician called time of death, and the entire operation was shut down.

I looked at the man on the table, who was now just a body to all the doctors and nurses and techs in the room. His eyes were partly open, and he still wore a bling watch on his left wrist, as if time still mattered to him. I wondered what he experienced, if anything, in those last few moments before the doctors decided that he could not be saved. If he had survived, would he have reported some sort of near-death experience like walking toward a bright light or talking to a dead relative? That would be too Hollywood.

I asked another doctor, after all the excitement had passed, why his death was so quickly called. Her answer was that we have to weigh the morbidities for someone who has been down for almost a half-hour. Even if they had been able to re-establish a heartbeat, it's likely that this man would have suffered severe brain damage, possibly to the point of persisting in a vegetative state.

In my training to become a doctor, I am certain to witness death again. It is inescapable, because Life is the currency of the profession that I chose.

Phlebotomy lab

This morning, as part of the Blood and Lymph block, we learned how to draw blood by practicing on each other. I didn't allow myself much time to get nervous about the prospect of tearing up one of my classmate's veins - or having my own veins stuck. Medical school is a series of new experiences, some of which are kind of intimidating because someone else has placed their trust in me to handle their body and do them no harm. I've found that the best way of coping with these types of new experiences is to first acknowledge to myself that I'm a little nervous, think clearly through what must be done, then to jump right in and do my best.

We were given a 5 minute introductory video, a page of instructions, all the necessary supplies, and one instructor per dozen students, then we were set loose on each other. I was fortunate to pair up with my dear friend Dreas, who is perhaps the most chill medical student I know.


I drew his blood first. I surprised myself by how steadily I was able to hold the butterfly needle, despite my nervousness. I hit his antecubital vein (the one in the middle of the crook of his arm) on the first stick and drew two tubes of blood.

But as I was getting ready to take the needle out, my hand accidentally caught on the tubing and yanked the needle out of Dreas's arm. "Oh no! Oh no! Are you alright?" Luckily, the nurse instructor was nearby and calmly told me to get some gauze and put pressure on it. "Yeah, I'm fine, don't worry about it!" Dreas laughed after we got the situation under control. The nurse was laughing at this point, too: "Oh, that was a good one!" The terror of almost shredding Dreas's vein gave way to embarrassment and then to humor. It's a good story to tell, I guess. Now I know to always keep my hand on the butterfly needle, and I won't ever make that mistake with a real patient.

Dreas drew my blood next and did an excellent job. I didn't even bruise.

First semester: Check.

The first semester is finished. Winter break is just about over. I took my relaxing seriously: lots of sleeping in, watching movies, reading for pleasure, playing games, spending time with my friends and family, running, and absolutely nothing related to medical school for two whole weeks.

Well, that's not entirely true, because everyone wanted to hear all about medical school. I found myself having the same so-how-was-first-semester? conversation over and over again (no mistaking - I enjoy relating my experiences). Just like my two weeks of Winter vacation, this first semester was over in a flash before I even knew what hit me. As I have talked with those who have gone through medical school before me, they all say the same thing, that it's all like this, a whirlwind.

Going into medical school, I was somewhat preoccupied by how many first and second year medical students I knew who were absolutely miserable because of the didactic curriculum and the sheer volume of information to absorb in such a short period of time. I for sure found my first semester of medical school to be grueling, but despite the intense work load (or perhaps because I'm that masochistic?) I genuinely enjoyed this first semester. Now that I'm all rested up again, I'm looking forward to starting Round 2 bright and early tomorrow morning.

Next up: Blood & Lymph, and Disease & Defense, which run concurrently during the first half of this semester. More on those courses later.