Friday, November 30, 2007

More Bad Pregnancy Outcomes

Yesterday I had my MS class in the morning. We're getting close to the end now: only two more weeks to go. Not that I'm counting the days until I won't have to get up for a 7 AM class any more or anything. ;-)

Today we finished the PBL case about the HIV positive woman who wants to have a baby. The story has a partially positive ending. The baby isn't HIV-positive, but he does have a genetic abnormality. What really got people fired up though are the ethical issues, particularly one of this week's CAPPs that revolves around the issue of a pregnant patient who refuses care. That's a sticky issue, because you can't force a competent adult woman to receive needed medical care, but most people would also feel a desire to intervene to protect the fetus.

The seminars were about pre-eclampsia (a type of hypertension that pregnant women can get) and ectopic pregnancies (where the fetus doesn't implant in the uterus like it's supposed to). Not exactly the cheeriest subjects. Our POD/ARM talk was supposed to be about pregnancy related disorders, but instead it wound up being about a particular transcription factor (protein) that is expressed by cells that are "destined" to become parathyroid hormone cells. The researchers discovered that if they knocked this protein out in mice, some of the thymus cells became parathyroid type cells and started secreting parathyroid hormone. However, this does not happen in humans. Well, on the bright side, at least I'll know what to do in case I ever get a mouse that is deficient in this transcription factor coming into my office for help some day. And I also wrote my second essay for MS credit based on this talk, so it forced me to pay attention. Now I only have to do one more essay in January.

Tomorrow is Doc Opera already. I really enjoyed it last year, and I have been looking forward to this year's show.

Wednesday, November 28, 2007

Medical Genetics

I've been getting quite a lot of exposure to medical genetics lately. First, I did my learning objective for PBL on genetic counseling and ethics. As I mentioned yesterday, this week's case is about an HIV-positive woman who wants to have a baby. Obviously, there are many legal and ethical issues that would arise, from preventing transmission of HIV to the husband, to avoiding transmission to the infant, to genetic counseling of the woman for birth defects of the fetus. Today's seminar was on the use of drugs (both legal and illegal) during pregnancy, which isn't really related to genetics. But then this afternoon, I had genetics clinic.

Genetics clinic turned out to be pretty interesting. I expected most of the patients to be babies, but many aren't. They range in age from little kids all the way up to old people. We did see one baby who was developmentally delayed. But we also saw one woman in her thirties with an unknown genetic condition that caused her to be mentally retarded and have some other physical abnormalities. Probably the coolest patient was a teenager who had blue scleras due to type I osteogenesis imperfecta. (The whites of people's eyes who have this condition really do look noticeably bluish--see picture.) His family was there with him, and his dad and brother had blue scleras also, but they didn't have the same history of broken bones that the patient had. The medical geneticist took pictures of the patients after we examined them.

The one thing I felt kind of bad about is that I was so tired this afternoon that it was hard to stay focused. Medical genetics is very cool, like a detective hunt. We were looking up all kinds of info about genes on line in between patients. But the problem is that there is a lot of downtime, and I had a hard time staying awake. I just hope the preceptor didn't think I was bored, because I didn't feel that way at all. If I were going to go into internal medicine, medical genetics would definitely be one of the specialties I would consider.

Tuesday, November 27, 2007

Reproductive Biology

This week we started reproductive medicine. Our PBL case is about another couple that is trying to get pregnant--this time, the woman is HIV-positive and the man is HIV-negative. The woman also has genital warts. These viral infections certainly add to the complexity of the case. The seminars are about all of the things that can go wrong with pregnancy. All I can say is that no sane woman should go to medical school until AFTER she has her kids. There is definitely such a thing as having too much information! Yesterday we talked about some of the infections that pregnant women can get, and today we learned about fetal genetic defects and placental problems. I have a much better appreciation now about why pregnancy is so dangerous for women. Throw in all of the genetic defects that the fetus can have, and it's amazing any pregnancy ever comes out right at all.

Our FCM seminar today was about alternative and complementary medicine. My group's preceptor didn't show up, so after twenty minutes I went to the library to read. That was an extra hour of reading time that I hadn't expected, but it was greatly appreciated. I'm actually going to be completely prepared for tomorrow's seminar.

We were really busy in clinic today. My preceptor and I used to only see six people on my clinic days, but now we're seeing seven patients each day due to a new departmental policy. You wouldn't think that adding one more patient to the schedule would be that big of a deal, but they are adding the last patient in the 4:00 time slot. So now the two of us really have to push to get everything done at the end. I saw five patients instead of my usual four. There was one diabetic, one with migraine headaches, one with a cold, one with moles that "looked funny," and one who just needed a checkup. It was a busy day, but I suppose I should be grateful that there wasn't anyone who was trying to get pregnant!

Wednesday, November 21, 2007

Happy Thanksgiving!

I found out today that the UP students had this whole week off, the lucky dogs. I can't complain though, because at least I got out of having clinic this afternoon. I was supposed to have breast clinic, but I withdrew because I would rather do genetics clinic next week. I've already done enough breast exams in clinic to last me a lifetime.

Both of our seminars today were yet again depressing, on cervical and uterine cancers. At least the PBL case had a happy ending. We were pretty rushed though since we had eight learning objectives plus three parts of the case to go through, and we had to fill out the weekly eval today too. I was unlucky enough to be the group leader this week, and although it was rushed, somehow we managed to get everything done more or less on time.

Anyway, I have the rest of this week off and I plan to enjoy it. I'm going for dinner with friends tonight and having Thanksgiving at a friend's house tomorrow. We have SAQs to do this weekend but no CAPPs. It really WILL almost be like a vacation. :-P

Tuesday, November 20, 2007

Spiritual Madness

Today was one of those crazy days where I think back on it later and kind of just shake my head. We had not one, not two, but THREE seminars this morning about prostate and testicular pathology. They were one after another, each with its own reading. All of them were great seminars, but three in a row was just a little over the top.

Then there was FCM. They had this guy from pastoral care come to give us a seminar. He was supposed to be talking about spirituality and how it affects decision-making in medicine. Instead, he wound up getting into a fight with about half the students in my class and half the preceptors too, because he was saying things like that ministers are the only people with proper training to help patients spiritually. That really got the doctors' dander up. He was also asking ridiculous questions like how we thought the case patient felt when she was having sex at the age of 11. Ok, first of all, this case patient is a composite, not a real person. Second of all, it's not like she was there and we could ask her! How the heck would we know what an imaginary person felt while having sex twenty years ago? The whole exchange was very hostile, and the FCM faculty wound up emailing the entire class this afternoon to apologize for the speaker's behavior. We didn't learn much, but at least for once I can say that an FCM session was exciting!

I had clinic in the afternoon. When I got there, it turned out that my preceptor was on vacation all this week and no one had told me. The nurses said I could go home, but I didn't want to have to make up the clinic. So I wound up working with one of the residents and his preceptor instead. He had a patient who needed a neuro exam, and he let me do it. At long last, I pretty much have the cranial nerve exam down, and no one has to prompt me because I forgot to examine CN 11 or something.

There is a pharmacist in our clinic who meets with patients, and I went into a room with her resident on one patient also. That was really interesting because I had no idea what the pharmacists did in the clinic. It turns out that they counsel patients with tough cases who take lots of meds. This particular patient was a diabetic who was completely noncompliant and was also hypertensive, obese, and dyslipidemic. The most interesting part to me was how different the focus was. The pharmacists really don't get much into the disease symptoms or mechanisms at all. After the resident presented to the senior, they were debating for 15 minutes about which type of insulin was best for this patient, and so I got a review of all the different long and short-acting insulins. When they were done, the pharmacist asked me what I thought we should do. I said, "Tell the patient to drink diet soda instead of regular soda." All the insulin in the world is not going to help a patient who drinks a six pack of sugar water every day!

Monday, November 19, 2007

The Problems of Women and Men

So far this has been a very depressing week as far as classes go. Our PBL case patient has genital warts and cervical cancer. The two seminars today, although interesting and well-done, were about breast cancer. This is going to go on for the rest of the week--tomorrow, we're covering male genitourinary problems, and Wednesday we're back to women. One interesting thing I noticed is that our pathology book has tons more coverage of women's health problems than men's. There are two separate chapters on women's health, one just on breast diseases and another huge one about diseases of the female reproductive tract. The sole men's health chapter is much shorter. I wonder if this is because there are that many more diseases of the female reproductive tract, or if we just know more about women's diseases?

Speaking of genitourinary tracts, this evening I did my GU exams at the Cleveland Free Clinic. It was quite an experience. Two of my classmates and I got there at 4:45, and we first got a pep talk of sorts by the woman who coordinates the medical student practice exams. She spent about half an hour telling us that we had to be professional, and giving us all kinds of ideas of how NOT to be professional that I would never have been clever enough to have come up with on my own if she hadn't described them in excruciating detail. Like, apparently in the past some med students have said they were going to the bathroom, but then bailed instead without telling anyone. She warned us not to sneak out of the clinic, or she'd have to report us to the school. I had to laugh, because as much as I was not looking forward to performing a digital rectal exam, I haven't come this far and worked this hard to let something like this stop me from getting my MD. So none of us bailed, and we managed to mostly stay awake during an incredibly boring video about Pap smears that, judging from the clothing the actors wore and the equipment being used, must have been made in the late 70s or early 80s.

After an hour of these torments, we were finally ready to do the female exam. Since there were three of us students, we were divided into one pair and one single person. I was the single person, and I had a sort of coach in the room to help me along with the patient herself. My standardized patient and the coach were super helpful, and once they started giving me instructions I got over the weirdness of the situation pretty quickly. First, we went through the breast exam, which I had done several times in longitudinal clinic already. No biggie. Then it was time for the pelvic exam. (We inserted the speculum, but didn't do the actual Pap smear.) I inserted the speculum and was able to visualize the os (opening) of her cervix on the first try. Then I tried to palpate her ovaries (I couldn't really feel them) and did the rectal exam. It wasn't too bad because I was so focused on what I was doing that I didn't even think about the grossness factor.

All that was left to do was the male exam. Since I was done first, I got to spend another 20 minutes one-on-one with the coordinator lady and hear about more blunders committed by previous medical students over the years. When the male standardized patients arrived, one of my classmates and I were paired together this time. That standardized patient was really awesome also. He started by explaining the exam, and then I went first. The male exam was a lot more uncomfortable for me than the female exam. The man was standing in front of me, and I was inspecting his penis and testes while seated, which felt pretty awkward. The weirdest part was when I was examining for an inguinal hernia. He didn't have a hernia, so I had to palpate pretty deeply into his inguinal canal to reach the inguinal ring. When he coughed I could actually feel his intestines move. After my classmate repeated the exam, we moved on to examining the prostate, which entailed yet another digital rectal exam. I was able to palpate the prostate, but it was hard to reach the far edges. Prostates are larger than I had realized.

We were finished at 9:00, and I was definitely glad to be done. Doing the GU exams wasn't as awful as some people make them out to be--you're so busy concentrating on the exam that you don't really have time to sit there and think about how gross it is. But at the same time, I am absolutely certain that I have zero desire to go into either gynecology or urology. Even though doing the GU exams wasn't all that big of a deal, I am definitely not looking to make a career out of it.

Friday, November 16, 2007

Conferences, Incontinence, and In Vitro Fertilization

The conference I went to yesterday was really good, but I'm glad it's the last one that I'll be attending for a while. It's amazing how much these conferences totally screwed up my schedule. I also missed my MS class (which I have to confess that I'm not especially sorry about) and a Dean's Dinner by Steve Nissen (which I am definitely sorry about). That was the first Dean's Dinner that I've missed since I started med school, and I would have loved to have gone. I've seen him talk once before about his work on intravascular ultrasound, and he was supposed to discuss that again last night. But apparently he wound up discussing the whole Avandia brouhaha due to his meta-analysis that was published earlier this year.

Our PBL case had a very happy ending, and our only seminar today was anatomy. This was a review of the genitourinary systems of the male and female. The talk at the beginning was about different kinds of urinary incontinence. One type, called stress incontinence, can happen due to an anatomic problem when pressure increases in the abdomen (ex. from laughing or coughing). The other type is urge incontinence, which is due to a neurological type of problem. The difference is important because urge incontinence can be treated medically, while stress incontinence tends not to respond to medication and has to be fixed surgically.

I met with my PA also and we discussed my portfolio essay and my plans for next year. Right now I am tentatively planning to do Core I (medicine and surgery) starting in July, then a block of research and electives starting in November, and then Core II (neuro/ob/gyn/psych/peds) in March. I would probably then do my Advanced Cores in July of my fourth year and start my research year afterward in November. This will give me time to write a proposal and get it approved by the CCF IRB.

Our POD speaker today (sorry, our ARM speaker today) is doing research in infertility and in vitro fertilization. He was a really engaging speaker who told us a bunch of interesting anecdotes about the early days of in vitro fertilization. For example, he was involved with the first in vitro fertilization that was done in the state of Ohio, which was in 1983, and he was the first person in the world to implant an in vitro-fertilized embryo into a surrogate mother. Currently he has a project that raises money to help pay for gamete storage and in vitro fertilization for lower-income patients who could not otherwise afford it. The program particularly targets young female cancer patients who are undergoing radiation that could render them infertile and incapable of having children at a later date.

The talk was certainly enjoyable and the research was very interesting. But I can't quite push this nagging thought out of my mind that as frustrating as infertility must be to people who really want a child, it's maybe not the most pressing problem in all of medicine. Why should in vitro fertilization deserve so much of our limited supplies of funding and brainpower? No woman is going to die if she can't become pregnant, and couples who cannot have their own biological children can always adopt a child. I'm not saying that this kind of research shouldn't be done or that the technology for in vitro fertilization shouldn't be used. It's just that there are plenty of life-threatening problems that could possibly be ameliorated by setting up foundations to subsidize health care costs for lower-income people whose jobs don't provide them with health insurance. For example, why isn't there a foundation to subsidize yearly Pap smears for low-income women so that they don't die of cervical cancer that could have been treatable if it had been caught earlier?

Wednesday, November 14, 2007

PBL, Pharm, Peds Clinic, and Portfolio

Today's portion of the CCLCM curriculum is obviously sponsored by the letter P.

Our PBL case took a little twist that seems kind of farfetched, but at least it kept things interesting. I wasn't able to find any good pictures about my learning objective topic, so I had to do a "chalk talk" for my presentation. The only reason I don't like doing that is because then there's nothing for people to look at later on the portal, but it couldn't be helped. After PBL, we had a seminar about contraceptives. I like the pharmacist who led the seminar, but this seminar didn't seem to go very smoothly. She has led other seminars for us before, and I don't remember them being this disjointed. We had a lot of time in between discussing questions where we were supposed to be looking things up in small groups, but I don't feel like I got as much out of it as usual, and people weren't participating much today. Maybe it's a general feeling of being tired and ready for Thanksgiving, and plus our first portfolios are due tomorrow. I already finished mine and submitted it. I had to get it done early because I'm going to a conference tomorrow.

Peds clinic this afternoon was great again. I was working with the same adolescent medicine specialist that I worked with last time, and we saw a bunch of really interesting cases. This time there were a couple of little kids thrown in there too, and I even enjoyed examining them since they weren't screaming. The one kid who did scream was an older kid who I swear had a temper tantrum right there in the doctor's office, but luckily I didn't have to examine that one. There's something particularly irritating to me about really little kids screaming--I think it's just that their screams are so shrill. Even though I really like adolescent medicine, I'm not sure I'd realistically survive a three year peds residency.

Tuesday, November 13, 2007

Endo/Repro Block, Round II

Yesterday was our first day of Endocrinology and Reproductive Biology (ERB). Evidently the ERB faculty have decided to follow the NMS pattern and give us two seminars per day. That would be fine--it would be great, actually--if they didn't also double the reading we're supposed to do! It's absolutely impossible to get it all done and still have time to eat, breathe, and sleep. I'm at about half done, half not so far this week.

Yesterday's seminars were on uterus pathology and pain during menstruation, and today's were on male hormones and menstrual disorders. So far they've all been well done on the whole. Our PBL case this week is good too. It's about an infertile couple, so there are a lot of potential problems in our differential. I really like my new PBL tutor. We're his first group, but he's a lot more involved than my tutor last block was, and yesterday's session went noticeably smoother versus last block. Today's FCM session was about improving performance measurements to increase the quality of health care systems, which has to be one of the least interesting topics I can possibly imagine. I know it's an important issue, and I understand why I should know something about it, but I can't say that I'm particularly fired up about which methods we can use to assess hospital performance.

My observed history and physical (H & P) was today, and it went really well. I had an hour and a half to get my patient's history and examine her while my preceptor sat in the corner and kept track of what I was doing. (This was a real patient, not a standardized patient.) The patient was really funny. When I went through the review of systems, she pretty much had every problem I asked about. She also was one of those patients who likes to go off on tangents, so I had to use a lot of closed-ended questions to keep her on track so I wouldn't run over time. There were a few things that I forgot to ask about (family history, illegal drug use) and do (listen for murmurs in the carotid arteries of the neck). But overall my preceptor was happy with how I did and gave me a really good eval. And this time, I did remember to examine both the heart and the liver from the patient's right side. :-) After the H & P, I had an hour to write it up and then 15 minutes to present it to my preceptor. I had to make a few corrections before submitting my final copy, and I'm done.

My take-home exam from the summer epidemiology class is due on Thursday, but I'm pretty much done with it. There was one question that I am pretty sure I got wrong, but I don't know how to fix it, and I am not allowed to ask anyone for help. Hopefully I'm at least on the right track, but at this point I am pretty much out of time and just need to turn it in.

Friday, November 09, 2007

Last Day of Neuro Block!

So amazingly, I have survived this entire NMS block, and sometimes I actually even liked it. All three of our PBL "caselets" for this week ended happily, including the noncompliant patient, who suddenly saw the light and became compliant. Obviously, this PBL case is not totally true to life! The seminar was about vision. Although the speaker was good, I had a hard time focusing. I just wasn't very mentally with it today, and it didn't help that I hadn't been able to get any of today's reading assignment done ahead of time.

Our POD speaker was FANTASTIC. His talk was supposed to be about pain, but instead he was discussing the relationship between depression and cardiovascular disease. Apparently in both cases, there are cytokines (inflammatory immune system proteins) that get upregulated. It isn't known if that is a cause or an effect, but in either case, people who are depressed tend to have more cardiovascular disease, and people who have cardiovascular disease have worse prognoses if they are depressed. I was thinking about this idea of inflammatory cytokines being related to cardiovascular disease and depression, and it hit me that if this hypothesis is true, then people with autoimmune disorders like rheumatoid arthritis ought to have a greater risk of depression and cardiovascular disease. I looked it up, and sure enough, they do. I wound up designing an experiment and writing an essay around this idea. I am required to write three of these essays (just 1-2 pages each) in order to get MS credit for the POD course, so now I only have two left to do.

Thursday, November 08, 2007

Visiting an Abortion Clinic

Today was quite an interesting day. I had my MS class this morning, and it was actually enjoyable. The same statistician that I really liked last summer gave the first half of the class, and one of the statisticians I had worked with over the summer for my research gave the other half.

Last week, one of my classmates had invited all of the CCLCM students to visit Preterm, which is an abortion clinic about ten minutes away from CCF in Shaker Square. There is a student group for choice at Case, and a bunch of Case students went today, along with about half a dozen of us from CCLCM. Visiting an abortion clinic was both a disturbing and informative experience, and it's probably something that every medical student nationwide ought to do.

The clinic staff began by giving us an orientation to the clinic and what services are provided there. (They provide counseling services and birth control as well as abortions.) We were also given statistics about abortions, abortion access, and political efforts to keep abortion legal versus outlaw it. One thing I hadn't realized is that Ohio has a pretty extreme, staunchly anti-choice state legislature. One representative apparently introduced a bill that would outlaw all abortions, even if it was necessary to save the life of the woman. They also passed around a pro-choice petition for people to sign. I am not registered to vote in Ohio, so it wasn't an issue for me to decide if I even wanted to support pro-choice legislation, but I'm not sure I would have signed regardless. That is mainly because I felt the orientation was a bit overly proselytistic and defensive. But I suppose it's understandable that it would be, considering that the clinic employees have rude protesters outside their place of work shouting nasty things at them and their clients every day.

The more interesting part was when the staff demonstrated how the abortions were done. I didn't know very much about abortion procedures before visiting the clinic, and the surgery procedure in particular was nothing like what I expected. Most women get abortions during their first trimester using vacuum aspiration. The abortion is performed by first dilating their cervix, and then inserting the vacuum cannula and suctioning the embryo out of there. It only takes a few minutes to do the suctioning from start to finish, and no further surgery is required. They had models of a woman's cervix and manual vacuum pumps that were basically like giant syringes so that we could see what it was like to perform the procedure ourselves. It was surprisingly easy to do once I got the hang of using the vacuum pump.

Alternatively, the patient can be given a medical abortion using drugs that interfere with progesterone activity and prostaglandins, which stimulate uterine contraction. (Progesterone is the hormone that maintains the uterine lining during pregnancy.) She takes one pill at the clinic and then a second one at home the following day. This method of abortion actually has a higher rate of complication versus the first method.

If the woman is past her first trimester, other methods like dilation and evacuation (D & E) have to be used. These are the infamous "partial birth" abortions, where the woman's cervix is dilated, and then the fetus is partially delivered, disassembled and pulled out of the uterus piece by piece. The physician described the procedure to us, and it was pretty graphic and gruesome. He explained that although Congress tried to outlaw D & E a few years ago, it is still performed in this country. The main difference is that they apparently used to do it on a living fetus, and now they are required to kill the fetus first before removing it from the woman's uterus.

I can't agree with what I view as Preterm's completely amoral stance about abortion. As a person who is devoting my life to "doing no harm," I do consider abortion to be a "necessary evil," and I do not agree that abortion is just another form of birth control. Unplanned pregnancies are tragic, and so are the abortions themselves. If that makes me "judgmental," then I suppose I am guilty as charged.

Wednesday, November 07, 2007

PBL, Hearing, Vestibular, and Clinical Correlations

Today's PBL session was kind of nuts. We had a few other mini cases besides the one we started on Monday, and it was just really disjointed. "After seeing Patient A and prescribing her medication Y, Dr. X goes into the next room to see patient B. Patient B's symptoms are...." So it wound up being a list of symptoms that we used to figure out what kind of headaches the patients were having. We found one of the patient descriptions almost word-for-word on the internet. I don't know if that says more about the case writer's lack of creativity or the medical students' mad googling skills.

I didn't get a chance to do the reading for either seminar today, but it was ok because I was able to skim through the chapters during the seminars. The first seminar was about the vestibular system, and the seminar leader, although a nice guy and clearly trying to do his best, was way overambitious. He had 69 slides for a 50-minute seminar! Unsurprisingly, he had to deliver his talk at breakneck speed, and we ran way over. The second seminar was about hearing. It was given by two audiologists. I hadn't realized that any audiologists worked at CCF, but there are at least two. Audiologists treat patients with hearing or vestibular problems, but they aren't physicians. They have their own degree called a doctorate of audiology. These two audiologists were both really nice too, but their seminar had the opposite problem--it was kind of repetitive and not the most interesting.

In the afternoon, I had two clinical correlations. The first one was for doing neurological exams on patients with neuro disorders, and it was really great. We saw patients with Parkinson's disease (PD) and multiple sclerosis. One of the PD patients has a deep brain stimulator (DBS) implanted, and he turned it off for us so that we could see how bad his tremors were without it. DBS is incredibly cool technology and its use in PD is becoming more common. In a nutshell, the patient gets a sort of pacemaker implanted into an area of their brain called the globus pallidus. The neurons there are part of a movement pathway from another area called the substantia nigra, and neurons from the substantia nigra get destroyed in PD. The pathways are pretty complex, but the end result is a lack of volitional movement, and that's what DBS can help overcome. (If you're interested in DBS, you can read more about it here.)

The second clinical correlation wasn't very good, but apparently some of the other groups had a better experience. My group wound up waiting for half an hour at the desk in the neuro ICU. The secretary paged the doctor for us, and he said he would come get us, but no one ever came. So finally, we started wandering around the neuro ICU until we ran into another doc who took us in to see one of the comatose patients and went through the general procedure of how they examine these patients. We didn't get to actually examine the patient though, and I didn't really get much out of it. It was especially hard to concentrate on what the doctor was saying because the TV was blaring overhead. I'm not into watching soap operas, but I think I learned more about two of the characters' plans to set up another character than I did about examining a comatose patient.

The one thing though that I did take away from this otherwise useless experience was a better understanding of why it is so difficult for physicians and family members to disconnect brain-dead patients from respirators and feeding tubes. Our patient was in a persistent vegetative state, but sometimes he would spontaneously open his eyes, start breathing harder as if he were gasping for air, and make other slight movements. Even though his higher brain function is completely gone, he does not respond in any way whatsoever to painful stimuli, and there is no chance that he will ever wake up, seeing him make those spontaneous movements gives the observer an impression like he's still aware on some level. I can only imagine if I felt that way how an emotional family member with no medical training and a fervent desire to have their loved one back would refuse to believe that this person could never wake up. As it turns out, this particular patient's family does not want to disconnect him from the respirator.

Tuesday, November 06, 2007

All About Pain

I've spent the past two days learning about pain, thinking about pain, and reading about pain, but luckily not experiencing too much of it, at least not physically. Yesterday, we had a PBL case and a seminar that were both about pain, and today we had an anatomy session about the trigeminal system. The trigeminal nerve is one of the cranial nerves that innervates the face. (It's the fifth cranial nerve, if you were wondering.) As you can see in the picture, the trigeminal has three branches that go to the forehead, cheeks, and chin, and they all detect pain in the face among other things. Pain is a very complex sense, because it has such a huge emotional component to it. If you're afraid of the pain, it can actually make your pain worse.

We had FCM this week, and it was about health care policy decisions. There were no small groups--we just had a speaker from the Case Business School for the full hour and a half. This same guy has spoken to us before. I think most of my classmates liked his talk, but I have to say that health care policy bores me to tears. It was, well, kind painful to sit through an hour and a half long lecture on it.

In clinic this afternoon, I had a patient who fit in with the whole pain theme perfectly--she has severe, chronic migraine headaches. There wasn't much for me to do about the migraines besides take the history because the patient was already being followed up at the CCF Pain Clinic. But still, we had quite a lengthy discussion about possible triggers, how the headaches affect her quality of life, and so on. I get an occasional headache myself every now and then, but nothing like this poor patient.

I meant to ask my preceptor today if patients who fit the topics we are covering in school are being booked this way on purpose. If not, this has to be the longest string of coincidences I've ever experienced. Or, maybe it's just that symptoms like pain and headaches are so ubiquitous and I haven't been keeping track of how many previous patients I've seen with headaches. Now that I think about it, patient complaints of headaches aren't exactly rare. If you go through the review of systems with a patient and ask them if they have this or that symptom, almost everyone will say yes to headaches. Who doesn't get a headache every now and then?

Monday, November 05, 2007

Blogger Challenge Update

Yesterday, a very generous reader donated the remaining amount needed to fully fund the Mississippi skeleton project. I received a very nice letter from the teacher of this class, and I would like to post it here so that everyone who contributed to funding this project will know how much this teacher and her students appreciate what you've done for them.

Thank you so much! I cannot wait until school takes in on Monday to tell my students about your wonderful gift to them! They will be thrilled! Words cannot express the gratitude that I feel. The impact of your generosity will continue through the years to come, and I will make certain that my students remember that a stranger out there cared enough about them to make sure they got what they needed for their education. You will never know the boost to their esteem that such thing produces. Again, thank you from the bottom of my heart, and on behalf of my students, bless you!

I would like to again thank ALL of you generous readers who have donated to the CCLCM Student Blogger Challenge. At this point, we have raised a grand total of $494 to help low-income middle school students, and we have fully funded the Mississippi skeleton project. However, the Bronx reading project still needs another $401. If any of you have been thinking about donating but haven't gotten around to it yet, please consider giving a few dollars so that we can get those books to the kids.

Also, I was looking around on Donors Choose some more over the weekend, and there are so many great medicine and science-themed projects that need funding. I wish I could fund them all. If some of you readers are looking to make a tax-deductible contribution to charity before 2007 slips away from us, here are some other projects that caught my eye. The expiration date is the date when Donors Choose will remove that proposal from their website if it has not been fully funded by that point.

Concentrated Science Investigation (CSI) is a proposal to buy a set of forensics kits for inner city middle school children in North Carolina--expires April 27

First Step Lab, Second Step Nursing School is a proposal to buy two balances for use by low-income, pre-nursing high school students in rural Mississipi--expires April 29

Skeleton in the Classroom is a proposal to buy a model skeleton for inner city elementary school children in Texas--expires June 16

1-2-3..Bison To The Rescue! is a proposal to buy CPR kits to train low income high school students to administer CPR in rural Alabama--expires June 24

Inner Space - What a Trip! is a proposal to buy prepared microscope slides for low income middle school children in rural Mississippi--expires June 27

Protons, Neutrons, Electrons - Oh My! is a proposal to buy chemistry models of DNA and atoms for low income middle school children in rural Mississippi--expires June 27

Exploring The Human Body is a proposal to buy a model of the human body for low income elementary and middle school children in inner city Chicago--expires June 29

Inspiring Future (Urban) Doctors and Nurses is a proposal to buy dissecting supplies for inner city high school students in Massachussetts--expires June 30

Friday, November 02, 2007

Utterly Exhausted

I keep foolishly thinking that things are finally going to slow down at some point, but they never do. This week was the worst yet. I have only managed to get about half of the week's reading done, and I didn't get any reading done for my MS class yesterday at all. Obviously, this is not going to be a fun weekend, and next week is not looking much better, unfortunately.

This morning's seminars were on neuropsychology and gait disorders. The neuropsychologist who did the neuropsych session came last year also. She was showing us the tests that they give to people to see if they have dementia. Even though we had seen all of these tests last year, it was really helpful to see them again. Somehow, I am just getting more out of seeing these things this year. I think it's because now I'm only 95% confused about neuro instead of a complete 100%. The second session was with Dr. Chemali, who gave us a neuro session on sensation last year. He didn't play Celine Dion for us this year, but we reviewed all of the spinal pathways, and again, it seems to all just be making more sense.

Our ARM session today was a follow-up to last week's small group session where we are ostensibly supposed to be learning about how to write grants. It was, to put it kindly, completely useless. Each group was supposed to give a brief presentation about the project they had come up with, and I volunteered myself and one of my none-too-thrilled classmates to present for our group. The presentations went better than I had expected, because they actually did generate some discussion. But all in all, it was still a pointless exercise in terms of its stated purpose to teach us about writing grants. I think I mentioned last week that you would always start working on a grant by reading the literature so that you knew what the problems in that field are, which we didn't do. That's a pretty important step to just skip over! We were just coming up with hypotheses and methods out of thin air, which doesn't really give a very realistic simulation of the grant-writing experience. This exercise really should be made more structured, if not eliminated from the curriculum altogether.