Last day of classes!

I just finished my last class of my first year! Woo hoo! Six days from now, after I finish the renal (kidney) exam, I will officially be a second-year medical student. I'm ready for a break.

Donor Memorial Service

Last week, a donor memorial service was held for all the people who donated their bodies to medical education. This was a joint effort put on the the Schools of Medicine, Dentistry, Physician Assistants, and Physical Therapists, all of which use cadaver dissection to teach anatomy. The service was meant to give thanks to the donors and provide closure to their families, who it should be noted had to endure a prolonged period of mourning necessitated by the donation process.

The service also provided closure for students - for myself. It feels like such a long time ago when we were up in the cadaver dissection lab, but in actuality it has been just half a year. The experience of dissecting a human being strongly affected me, which is probably why I avoided even thinking about the memorial service until it was suddenly upon me.

The service was beautifully done thanks to a lot of hard work put into it by a lot of people, including our class vice-president Ramya.

One highlight of the service that I found most meaningful was listening to the families of donors talk about their loved ones who made such a selfless gift. Not just their words but their very presence - seeing that the woman whose body I dissected left behind family who mourned her passing - finally revealed the depth of her humanity that was so carefully and purposefully hidden from us during the actual dissection.

A second highlight of the service was the speech given by my friend and classmate Evelyn, who delivered it with such sincerity that I was literally moved to tears. I am sharing Evelyn's speech here (in full, with her permission) because it so accurately reflects my own experiences and sentiments.

Hello, my name is Evelyn. I’m a first year medical student and it is my honor to share some thoughts on behalf of my class in the School of Medicine. I’d like to start by telling you a couple of anecdotes, a window into the lab so to speak for a few moments, so that you might know how incredible and meaningful this experience was that your loved one gave us.

Our donors’ bodies are carefully prepared and protected and we newbies have some trepidation meeting them for the first time. There is a tradition that dissection starts on the torso, and the person’s head, hands and feet remain “covered” until last. These are considered the most human parts of the body and so most likely to engender discomfort initially for us dissectors.

Yet it felt strange to me to make incisions into this person’s body without having any sense of who she was. So I asked the professor if I could unbind her head to see her and meet her before we started. Happily, he agreed. It made all the difference in the world to me. Quiet and peaceful now, she still had a band-aid on her forehead, a bruise where she had bumped into something unexpectedly, a gold tooth and an ethnicity different from my own. Here were the signifiers of a story, her narrative, her life that I was now privileged to enter.

Since real names are protected, somehow the name Doris emerged as a fitting way for our group to relate to her as a person. As we worked on her back, she showed us see how all the muscles that help us stand and bend and twist are arranged, and under those the vertebrae with those discs between them that can slip out of position and trouble us.

Then we came to the inner sanctuary of the spine. We opened up the dura mater covering, and there lay the spinal cord, soft and glistening, with a perfectly formed cauda equina of nerve roots at the end. It took my breath away. It was simply beautiful and strangely seemed so alive.

A thought flashed into my mind that she hadn’t ever seen this and I caught myself literally almost tapping her on the shoulder to say, “Look at this – it’s amazing!” even though she couldn’t really lift her head and peer down her own back to see the beauty that was hers.

In the coming years, whenever I perform a spinal tap procedure to get clues from a patient’s fluid for diagnosis, I will remember to be careful about positioning the needle to protect these vitally important nerves that Doris showed us.

Another afternoon, I got to dissect her heart. The heart is superb and well sheltered inside a resilient pericardial pouch and layers of fatty tissue. Holding it in this shapeless state I felt like a sculptor facing a block of stone, before those patient hands chisel away to reveal a hidden treasure.

I settled in beside her head at the dissection table, and with her heart in my hands, carefully removed these protective layers to expose the shape we know - the four chambers and the coronary arteries that surround and nourish it with oxygen.

Then I opened it up to reveal the clever valves inside and stunning chordae tendineae – literally the “heart strings” - that tug on these valves to keep them tethered as they do their work, opening and closing to help the heart pump blood around the body.

For four hours, it was Doris and I in a world of our own, this silent teacher showing me a wondrous vista. As I worked, I realized that this heart beat inside her chest for more years that I’ve been alive and how it symbolically held her stories of love given and received. I wished I knew those too.

And to each of you sitting here today I would like to recognize the huge gift you too have given us. I lost my own mother a few months ago. She was somebody I was very close to. And I recall how protective I was of her handing her body over to the morticians for a mere two days to prepare her for the viewing and funeral. But all of you have waited graciously for up to two years for us to do our work before you could get your loved one back. I can only imagine what effect that has had on your grieving and that it perhaps delayed closure for you. I do hope today brings comfort to you and to that process.

And in this time that you have waited so patiently, have you ever wondered, what’s going on over there? How are they treating my mother, father, brother or sister? Are they being gentle and kind to them? Do they value what they’ve been given? Are they being respectful? Are they learning anything meaningful? And don’t they know that that’s my kin, and are they treating them well?

I’d like to tell you today that the answer is “Oh yes. Oh yes indeed – as if it was our own mother, father, brother, sister, grandmother, or grandfather.” On behalf of my class, we sincerely thank you and your loved one for the extraordinary gift you chose to give us.

As we go forward in our careers, the technical aspects of anatomy that we learned through your generosity will most assuredly come with us and help us be better doctors. But just as importantly, it has shaped us as people, who understand just how unique each person is on the inside as well as the outside and accordingly how they might respond differently to our treatments. And who know now just what it is to value, respect and care for those who can no longer speak for themselves.

The last time I saw Doris was to take the final lab exam in Anatomy. Arriving at her table was like meeting a friend. I smiled seeing her and at knowing so intimately the structure on her body that was pinned for identification. At the end of these ten weeks, she was helping me one last time in the exam. I brought flowers that day and placed them in her dissected hand. I felt it was the least I could do to honor her - and to say goodbye.

Wherever you are, thank you Doris - and thank you to each of you.

Pulmonology, Denver style

I have run across an unforeseen complication of going to medical school in Denver. We're in the middle of the pulmonology section right now, and it turns out that altitude has an effect on lung function. Who'd have thunk?

Up here in the mile-high city, the atmospheric pressure is appreciably lower (thinner air) than the atmospheric pressure at sea level. Since this has real-world clinical relevance, especially during our third and fourth year clinical rotations, we have to know - and will be tested on - physiological values based on Denver's altitude.


PB = Barometric pressure (Torr)
PiO2 = Partial pressure of oxygen in inspired air (Torr)
PaO2 = Partial pressure of oxygen in arterial blood (mm Hg)
PaCO2 = Partial pressure of CO2 in arterial blood (mm Hg)
SaO2 = Saturation of oxygen in arterial blood (%)
CaO2 = Oxygen concentration in arterial blood (mL O2 / 100 mL blood)
CaCO2 = CO2 concentration arterial blood (mL CO2 / 100 mL blood)
[HCO3-] = Bicarbonate concentration in arterial blood (mM)

To be fair, every medical student in America has to learn (hopefully) a set of equations that relate all of these terms with each other. That means a medical student in Boston or New York or Los Angeles should be able to derive these values for a patient at any given altitude. The catch is that, here in Denver, we have to memorize two sets of values. It's worth noting that most USMLE Step 1 board questions will likely specify that the patient is at sea level.

From second look to CVPR

Right around this time last year, I was visiting for "second look" weekend. I had already been accepted, and the school was now trying to convince me to come here. (It worked.) I ended up staying with a guy in the class ahead of me, which gave me the chance to pick his brain about his experiences in medical school.

"What classes are you taking?" I asked him. CVPR. C-V-P-what? Cardiovascular-pulmonary-renal, he explained, and he talked about what kind of material they were learning. It all seemed way above me, I remember, like there were so many steps between second look weekend and CVPR that I couldn't fathom getting from here to there.

A year later, I've done it. We're in the middle of the CV part of CVPR, learning such bedrocks of medicine as interpreting electrocardiograms (EKG) and heart murmurs. This block is decidedly more clinical than either Blood and Lymph or Disease and Defense, a shift that has taken me a bit by surprise. It's a welcome change, though: a much more analytical approach to learning material that emphasizes the process of diagnosis based on clinical presentation (history and physical).

For a sneak peak into some of what we've been learning, here's the EKG Dance youtube video that explains different types of arrhythmias (when the heart doesn't beat in its usual coordinated manner): http://www.youtube.com/watch?v=asR2-sb27Vw

(Explanation: The heart has four chambers. Two ventricles pump blood to the lungs and the rest of the body, and two atria serve as filling chambers that help the ventricles do their job. Imagine the ventricles as this guy's legs and the atria as his arms.)

Mentored scholarly activity: Figuring things out

One of the graduation requirements is completion of a mentored scholarly activity (MSA). Such a research requirement is becoming more and more popular in medical education as competition for residency programs increases. The types of projects that fulfill this requirement can range from basic science research to clinical research to community health and epidemiological studies, or really anything that poses some sort of academic question related to the medical field. The requirements are quite lax. I see the MSA is a chance to explore my interests, gain some (more) research experience, and possibly publish a paper or two.

Global health: Uganda

Given my recent experiences in Honduras, I very much wanted to put together a Global Health project. I had several potential projects on the table, including one that would take me back to Honduras, one to Peru, and a third to Uganda.

The prospect of working and gaining clinical experience in any of those countries was intoxicating. Honduras fell through at the end of last semester because it would have been nearly impossible to put together a project from scratch in the limited amount of time available to me. I decided not to follow up on the Peru option mostly because I wasn't excited enough about the existing study. A group of students in the class of 2012 started this project and put a lot of time and hard work into it, which is why I felt like I wouldn't own it.

I did follow up on the Uganda option. A few weeks ago, I interviewed with the doctor who would be my mentor and was eventually offered a position that included a stipend award to cover travel costs. I would be working at a hospital in southern Uganda throughout this coming Summer. There isn't any pre-defined project, and I would be expected to develop one while I was over there then return sometime during my fourth year of medical school to wrap it up. I was very excited, especially because my older sister has already done a lot of work Uganda.

Clinical research: Deep brain stimulation in Parkinson's disease

At the same time as I was looking into international options for my MSA, I also wanted to explore other more traditional research options - "traditional" relative to my experience in clinical research. The reason for this was my concern (whether justified or not) that doing a more community based global health project might make me less competitive should I choose to apply to a more specialized residency program. In fact, I talked with Dr. Michaels (one of my professors) who in so many words recommended that, if I have a more "hard science" research option, I go that route and instead do an international rotation during my fourth year.

She asked me what kind of research I would do if I could do anything, and without even a pause I responded, "deep brain stimulation in Parkinson's disease." Then I should pursue that, she suggested, and she gave me the name of a neurosurgeon who I could contact. I followed up with this lead, and to make a long story less long, found a mentor who had a stagnant research project just waiting for someone like me to take the reins and move it forward.

Decision time: Global health or clinical research

With both offers on the table, Uganda and the DBS in Parkinson's disease project, I took a few days to think it over and weigh my options. What it came down to, though, is that I've been wanting to do exactly this kind of research ever since high school when I came to understand what it meant that my Grandpa Don had Parkinson's disease. Even back then, when I first read up on Parkinson's disease, I was fascinated by deep brain stimulation and its almost miraculous relief of motor symptoms. Uganda will always be there, as will the rest of the world. I have a feeling that I will have many opportunities to travel the world throughout my medical career, if I look for them. Until then, I'm very excited to be working on this study!

The title of my project:

"The burden of cerebral diffuse ischemic white matter disease, measured quantitatively on MRI, as a possible predictive factor of cognitive outcomes after subthalamic nucleus (STN) deep brain stimulation (DBS) surgery for Parkinson disease"

More details in a later post.

Medical students calling doctors by their first name

Earlier this week, I stopped by the Academic Building to drop off thank you letters to the two doctors who helped me with my Spring break clinical interlude. I was planning on just leaving the letters with their respective secretaries, but I turned the corner and Dr. S. was standing right there. "Hi Josh!" I said, reflexively. I was immediately mortified that I had called him by his first name.

Dr. S. is young for a neurosurgeon, has a very laid-back personality, and looks a lot like a friend of mine back home, all of which contributed to my mistakenly calling him by his first name. He didn't notice - or, at least, he didn't appear to care much about the informality. A quick mental calculation, and I decided that it would be more awkward apologizing for my slip-up than to mask my embarrassment and carry on. (Aside: He ended up showing me angiogram images of a patient with a very large aneurysm coming off the anterior cerebral artery and invited me to the surgery the next day. It would have been fascinating, but I regretfully declined because I had class.)

This incident brought up the issue of how medical students should address doctors. I grew up around doctors - none in my family, but many of my close family-friends are doctors, and I obviously call them by their first name. When I was doing research at UCSD, the doctors who I worked with regarded me as a colleague, and I also called them by their first name. As a medical student, though, I have entered a long-established pecking order in which seniority is given its due respect. With this in mind, I've developed the following guidelines for addressing doctors (to be taken with a grain of salt):

1. ALWAYS address an attending physician as "Doctor." If he/she invites me to be more familiar, I still address him/her as "Doctor" in the professional setting. Usually, I just try to dodge the situation entirely by avoiding the use of pronouns when possible.

2. ALWAYS address an established or older physician as "Doctor" at first. If interaction with this doctor is out of the clinical setting and he/she invites you to be more familiar, then I usually feel comfortable using his/her first name. Roles can change, though, and I would definitely switch back to "Doctor" if we were later interacting in a clinical setting.

3. ALWAYS address an intern/resident as "Doctor" at first, but it's likely that he/she will be much less formal with you and expect the same in return. I've found that younger doctors in general aren't quite used to their title yet and still remember clearly what it felt like to be a medical student. During my Spring break clinical interlude, every single resident introduced themselves to me by their first name and expected that I address them as such, even in the clinical setting.

These guidelines (which I've instinctively understood but never before spelled out as I did in this post) have helped me avoid most embarrassing breaches in etiquette - when I'm sensible enough to follow them.

Spring break: Interventional neuroradiology clinical interlude

At the end of last semester, my classmates and I were required to complete a clinical interlude. I spent mine in the emergency room then followed a cardiothoracic case (aortic dissection) upstairs to the operating room. I enjoyed the clinical interlude so much that I decided to spend a couple days out of my Spring break doing something similar.

I wanted to get exposure to neurosurgery/neurology/radiology and so arranged to shadow a neurosurgeon who practices interventional neuroradiology. It was really a perfect fit.

Interventional neuroradiology: Procedures

My clinical interlude started with an embolization procedure to fix an arteriovenous malformation, which is basically just a tangle of blood vessels in the brain that predisposes the patient to a constellation of complications (e.g. intracranial hemorrhage). The whole point of the embolization procedure is to selectively block off blood flow to the region of malformation to make surgical resection of the malformation easier. It's common for patients to have many embolization procedures before surgical resection, each time blocking off a few more blood vessels feeding the malformation. Yesterday was this patient's fourth embolism procedure.

It's extraordinary, when you think about it, that such a procedure is even possible. A catheter is inserted in the femoral artery in the groin area. From there, a wire is fed up through the abdominal and thoracic aorta, through the aortic arch, and into the brain via the carotid or vertebral arteries. What's even more amazing is what happens once the wire is inside the blood vessels of the brain, which get smaller and smaller as they continue to branch off.

Doctor S. navigated the maze of tortuous arteries simply by twisting the wire in his hands so the tip of the wire would point one direction or another. Meanwhile, he tracked his progress in real time using fluoroscopy. In this way, he was able to make his way to the arteriovenous malformation in the frontal lobe. Once there, a thick liquid substance called onyx was slowly injected into the artery to occlude it. The onyx moves through the artery like lava and interacts with components in the blood to harden and form a permanent plug. The onyx injection is also tracked in real time: it appears on the screen as a black blob that gradually fills the vessels surrounding the malformation. One of the primary concerns in tracking the onyx injection is to make sure that it doesn't enter the venous outflow, because then blood flowing into the malformation from other arteries would have fewer routes of escape and pressure would build up.

Fluoroscopy imaging involves radiation, which means that everyone in the operating room must wear protective lead shielding, including a lead neacklace to protect the thyroid. After so many hours, that lead sure did feel heavy! Also, I was excited that I got to scrub in. There's a particular way to put on the surgical gown and gloves in a sterile manner that has a way of exposing a novice. Being a first-year medical student, I have license to own up to my inexperience, and the nurses were great at showing me the ropes. During a diagnostic angiogram today, the nurse also took the time to explain to me how all the different types of catheters and wires work, which I greatly appreciated.

Academic day: Conferences

Tuesdays are academic days, so today after rounds in the neuro intensive care unit (NICU), I attended two conferences. The first was a neuro-oncology conference during which neurosurgeons, oncologists, radiologists, and pathologists all meet to discuss cases. This was a nice course correlate, considering I was recently studying pathology for Disease and Defense.

The second was a "Morbidity and Mortality" conference during which neurosurgeons presented recent cases that had complications. The real purpose of this conference, it seems, is to identify mistakes to learn from them and prevent them from happening again. Although the majority of complications were straightforward, a few cases prompted some animated debate. It was fascinating to watch this group of neurosurgeons think through a case together and argue their differing opinions (all in a collegial atmosphere, of course). There was also one patient who had intracranial bleeding that a resident explained by acknowledging that he had made a mistake. Mistakes happen; they are a reality of training. Still, I was somewhat surprised to hear it discussed so matter-of-factly. The resident obviously did not appear too pleased with himself, but the attending neurosurgeons talked through the case in an academic manner that highlighted the factors that led to the mistake. I'm glad that I was able to get a glimpse into this aspect of training.

Overall impressions

Even though it meant a shorter vacation back home, I'm very glad that I decided to set aside these two days of my Spring break for an unofficial clinical interlude: a welcome refresher of why I'm in medical school. I got my exposure to neurosurgery/neurology/radiology, I learned a lot about embolization and angiograms specifically, and I also networked with many doctors and residents who invited me to come back when I get the chance.

Now, it's time for a real vacation.

Medical hypnosis

I have always been fascinated by the brain and its mysteries, so this semester I took advantage of a medical hypnosis elective. It was just two classes, each two hours long, and really only served as a very brief introduction to the role of hypnosis in medicine.

What is hypnosis?

"A good date is a mutual hypnotic state."

Hypnosis is a special state of mind that is brought about by intensely focusing on something and is characterized by a sort of dissociation from self. Have you ever been driving home and, once you arrived, realized that you didn't remember how you got there because you had been driving on "autopilot?" You focused on the road and allowed your mind to relax into whatever thoughts it pleased so that you lost all sense of time, and your body mindlessly performed the motor tasks necessary to get you home. That's a hypnotic state: a combination of intense focus and relaxation that somehow lends a person more open to suggestion.

Inducing a state of hypnosis involves both of these elements, focus and relaxation. The instructor demonstrated this by hypnotizing the class, the five of us. He had us imagine a "safe space" in our mind and asked us to explore every little detail of it. I noticed that the suggestion was vague and open to interpretation. This is called a "lead and follow" technique: the operator (hypnotist) leads the patient in a given direction then follows where the patient's mind goes. The effect is to reinforce imagination as reality to induce a deeper hypnotic trance. Four out of the 5 of us experienced a hypnotic state. Some people are inherently more easily hypnotized, and some people are less so.

Being the hypnotist

Next, the instructor invited us to practice on each other. Sitting down with my classmate in front of me, ready to do and feel and imagine what I suggested, I had a much clearer understanding that only experience can teach of what it means to hold such strong control over another person's mind. The sensation was exhilarating and a bit unsettling. I quickly learned that not only my words themselves but how I spoke mattered greatly. So, despite the adrenaline pumping through my body, I was careful to speak in a calm and measured manner, slowly, so the full impact of my words could be absorbed.

I discovered that I am good at hypnosis! I induced a hypnotic state in my classmate quite easily, but I didn't know what to do with it. This was partly due to my inexperience as an operator, but it's also because there was no real purpose to the session other than to practice inducing a hypnotic state.

Hypnosis and medicine

Hypnosis is not just used in psychiatry, which is what I'm sure most people believe. The instructor pointed out that pain is a particularly good inducer of a hypnotic state because nothing better focuses one's attention than pain. In fact, a patient with pain is often in a hyper-suggestible state of mind. Then the doctor walks in the room wearing a white coat and/or stethoscope, which are both symbols associated with the promise of alleviating that pain. I have myself witnessed such a hyper-suggestible state in my own patients, for instance when a man in excruciating pain from a fractured rib allowed me to touch him in exactly the spot that hurt the most.

The meat-and-bones of this elective was first recognizing this unique psychological state that we'll see in many of our patients, and second to learn techniques to take advantage of it to better serve our patients. My favorite example was using a pinwheel to distract a child from pain (e.g. a splinter, a scrape, getting a shot). I wish I had had this trick up my sleeve last semester when I was giving children shots at Warren Village. Asking the kid to blow on the pinwheel first offers the child something else besides pain to focus on. More than that, though, there are physiological benefits to breathing deeply to blow on the pinwheel, and the pseudo-trance is strengthened by the immediate effect of watching the pinwheel twirl.

My first hypnosis patient

Some time after I finished the hypnosis elective, a classmate of mine was trying to study but couldn't concentrate because she was so tired. "I can hypnotize you to make you concentrate better," I suggested, half joking. But she said yes, and I got myself my first hypnosis patient. I hypnotized her easily enough and suggested that when she woke up she would feel energized to study more and a sharpness of mind so that she would understand and remember the material better. For what it's worth, she reported to me the next day that she was able to finish out the night studying, and she's sure that otherwise she would have fallen asleep in her books.

I'm eager to keep practicing hypnosis. Any volunteers?

Pre-hospital medicine

As part of a pre-hospital medicine elective, I did a 10-hour shift ambulance ride-along with a couple of paramedics. I took this elective because I wanted to get a better idea of what happens with patients before they arrive in the emergency room, but the experience ended up teaching me more about the general job duties and perspectives of a paramedic.

My shift started at 2:30 pm and went to 12:30 am. It was a rather slow night - good that few people were getting hurt, but unfortunate for me since it made for a boring experience. We didn't get our first call until 5:30. Over the course of the night, we only had 6 calls total, 4 of which were Code 10 (sirens blaring). My classmates who also did a ride-along had vastly different experiences: one was doing CPR in the back of the ambulance while a patient was having a heart attack.

During all that down time, the two paramedics who I was shadowing talked a lot about their various interactions with nurses and doctors. I found it interesting that they grouped the quality of their interactions with nurses according to the hospital (apparently each hospital has its own "culture"), but the quality of their interactions with doctors was based more on individual personality rather than a particular hospital's culture. If I got anything else out of this elective, my two paramedic friends reinforced the interdisciplinary teamwork lessons that were drilled into us last semester: doctors are one component of a medical team, and patient care is maximized when the team works well together.

I enjoyed my experience overall, and would recommend this elective to someone interested in emergency medicine, but I do wish the ride-along could have been a bit more exciting.

Intubation night

The Emergency Medicine Interest Group (EMIG) hosted intubation night on Monday. We were up in the anatomy lab practicing on cadavers how to intubate a patient, which just means sticking a tube down the patient's trachea to start artificial ventilation. I have seen this done many times during my experiences in the ER, so it was especially rewarding to learn the how's and why's of intubation.

The emergency medicine residents taught us how to use an instrument that pushes the tongue out of the way and has a light at the end of it to see down the throat and pull up on the trachea to allow passage of the tube. This is a metal instrument, so it's actually difficult to do without chipping teeth. Then, a small balloon is inflated to secure the tube in place, and the patient is ventilated with an air mask.

If the patient (or in the case, cadaver) was intubated correctly, the chest will rise with ventilation. The tricky part about intubation is getting the tube into the trachea rather than the esophagus. In the ER, the doctors verify that the tube was placed correctly by listening with a stethoscope to breathing sounds in both the chest and stomach: breathing sounds in the stomach indicates that the tube is placed in the esophagus, which is obviously a bad thing. Standard procedure in the ER is also to take a quick x-ray to make sure the tube is placed correctly. If the tube is inserted too far, it could go down the right or left bronchus and supply air to only one lung. That's also an obvious situation to avoid and another reason why doctors listen for breathing sounds on both sides.

I suppose the chances are rather slim that I'll actually be able to do this on a real patient anytime soon, but it's something to look forward to.