Warming Conversation

Evidence Based Living

2009-10-04T02:50:02Z

Where's the literature on how to know when what you've done is good enough?

And, since there's an audience and to keep this from being completely emo-I'm-gonna-hide-in-a-corner... What metrics do you use in day-to-day living to decide when you've done well vs. poorly in day to day life?

Pluses and minuses

2009-10-02T17:03:19Z

Minus: Just managed to (semi-accidentally) call out one of my instructors for potential breach of patient privacy. In a large group of people.
Plus: He forgave me.
Minus: Self-importantly offered to give a 5-minute schpiel on internet security and unencrypted email to the same group.
Plus: Someone actually was interested enough to take me up on the offer.

Overall, I guess a minor plus: Maybe my comments will make my fellow students and future colleagues think twice before assuming that email is secure.

In the Lab

2009-09-28T02:12:01Z

The day is beautiful, perfectly fitting for a wedding... or a funeral. All medical students in their first and second years are to attend a mandatory event: the memorial service for our cadavers.

Before we get to the event itself, however, you might want a bit of background on the anatomy lab and what we do there.

The anatomy lab at our university is a refrigerated room that lies behind an imposingly constructed door complete with digital combination lock. The laboratory is open 24/7 to the medical students who study there, in case someone's got a late-night yen for spinal cord inspection or for trying to figure out exactly why the medial pectoralis nerve lies lateral to the lateral pectoralis nerve.

The laboratory proper is divided into four subsections, each of which contains six dissection tables. The tables themselves look like something from a very expensive kitchen, or perhaps a yuppie version of an Aztec sacrificial slab. They're brushed stainless steel, about waist height, with a drain inset in the middle of the table to catch the inevitable effluvium. Underneath the drains are large buckets allowing the table freedom of movement (and probably avoiding legal troubles with improper disposal of human remains into the sewage system...).

On each table is a cadaver. They're wrapped in wet linen shrouds to keep them moist, then again in opaque white plastic shrouds to keep the linen and the cadaver from drying out. They're preserved once in a special antimicrobial embalming fluid, and we continue that preservation by liberal application of some sort of greenish necromantic potion that comes in a large plastic jug. Our dissection tools lie under the table, along with a large wooden block, a box for bones, and an assortment of sponges.

The entire room is lined five or six deep with bright flourescent lights. Along the edges are shelves containing random body parts. One shelf is full of skulls - bleached skulls, painted skulls, and one amazing example of a skull in some sort of solvent which has rendered it into a transparent ochre jelly version of Indiana Jones' crystal skull. Another shelf is full of feet, with a third devoted to knees. The creepiest of all, I think, is the shelf of nothing but forearms and hands. The hands are preserved in very fine detail - you can see how the individual trimmed their fingernails before they died.

If you're thinking that the room is spooky, you'd be right, and you'd be wrong. It might be unsettling to be in there late at night, on your own, with no one to keep you company but the deceased. In practice, though, it's been a hive of activity whenever I've been in there. Students pack the place during labs, huddled three or six to a table around their subjects of interest. Professors walk from table to table, quizzing students randomly and pointing out hard-to-see structures. One professor with a thick foreign accent speaks halting English but can find any anatomical structure known to man in 10 seconds flat using nothing but a blunt probe.

The dissections themselves are quite distracting. After the first hour or so of painstaking work in scraping away soft tissue without damaging nerves or muscles, you learn to completely ignore the fact that you're working on someone, and just see the body in front of you as a challenging artifact to be manipulated. Often we'll walk over to one of the myriad skeletons hanging from the walls to talk about a particular structure, barely thinking about the fact that the skeletons, too, were once people walking around and living their lives. The dissection procedures themselves are hard physical work - lifting bodies, scraping at skin, sticking your gloved fingers underneath fascia to separate the layers.

Every so often, though, I step back and imagine a word of thanks to the person who donated their body to the lab. You can see a bit of who he was, in the aquiline nose and the large strong hands. You can see a bit of what he went through, in the cancer port and the wasting of the muscles. All we really know about our cadaver is related to his physicality - his medical history, what his muscles and tendons look like underneath the skin, what color his hair was and where his metastases had spread before the cancer took his life.

This is the yang, I think, the dark, heavy muscled cloak that this man wore around. As students, we are getting to know it far more intimately and in far more detail than his family did. Than he did, even. But we know nothing of the yin, that light portion of himself which was a propagating wave form that manifested in action, personality, experience, habits. His family knew the yin, back when it was still present, and so in a strange way, having never met us, they are our complement in knowledge.

Which brings us back to the service, which will be coming soon in another post. I must go write up an assignment that is due tomorrow!

Yes, I'm aware that I'm a complete tease. The good news is it probably won't be too long - this is a light week for us, coming after three weeks of incredibly hard, detailed biochemistry and cell biology.

By popular demand...

2009-09-21T00:37:06Z

Below is a list of entries I've got queued up in my head. Which do you want most to read? I'll survey results by about this time tomorrow, and start working on the one that's most in-demand.

1) Patient presentation: Huntington's Disease (a genetic disorder that causes progressive brain damage later in life but can be detected before symptoms show)
2) Patient presentation: Down Syndrome (a genetic disorder that causes mental retardation)
3) Memorial service for the cadavers - speaking with family members about their loved ones... whom we were recently tearing apart on cold slabs.
4) Basic overview of breast cancer for the laymen
5) Patient presentation: Colon Cancer (specifically, a genetic variant which virtually guarantees CC)

It should be emphasized here - and this goes for all of my posts on medicine - that I am *not* writing this as a doctor. I'm most especially not writing any of these as *your* doctor. I am not qualified to give medical advice, so if you learn something from me that you think you might put into use, DOUBLE CHECK IT FROM A REPUTABLE SOURCE, preferably your doctor. Then believe their version.

My week in profile...

2009-09-21T00:16:55Z

Just in case you folks were wondering where I'd gone/why I haven't been posting often like I said I would.

This list ignores travel times, breakfast, and general self-maintenance.

Monday -
10:00-16:00: Classes.
15:45-17:30: Lecture (yep, stacked with above and below).
16:00-17:00: ANOTHER lecture that I ignored from 1600-1700.
17:00-18:30: Come home, listen to portions of the lecture from the morning again to make certain I got them.
18:30: Wife and son come home from day care.
18:30 - 20:00: Dinner and putting the baby to bed.
20:00-24:00: Reviewing lecture notes and portions of the class that ended at 16:00 that I missed b/c I had to run to the lecture at 15:45.

Tuesday - My birthday
10:00-12:00: Classes
12:00-13:00: Lecture on Pediatrics as a career
13:00-16:00: Relax (it -is- my birthday) while listening to lectures in the background. They're still going over my head (gotta love cell signaling molecules and their arbitrary names). Grocery shop on the way home.
16:00-18:15: Aikido club - first meeting. Showed up to take the temperature of the group. Seems like a good group, but it's way out of my way and meets during the time I often pick up our son from daycare.
18:15-19:00: Run home like a madman and shower to get ready for...
19:00-21:30: Fancy dinner with friends to celebrate birthday (among other things)
21:30-24:00: Come home rather smashed, clean house and listen to lectures once I sober up a bit.

Wednesday -
10:00-12:00: Classes
13:30-16:00: Memorial/gratitude ceremony for our cadavers (I hope to cover this in another post soon)
17:30: Pick up son from day care
17:30-20:00: Dinner, baby time, baby bedtime
20:00-24:00: Review of lectures and a couple of hours of cleaning - have to clean the house for the cleaners, of course

Thursday -
07:15: Get up to take care of baby
09:00-14:00: Classes
14:00-17:00: Review of lectures and grocery shopping.
17:30-20:30: Pick up son from day care, baby time (mall playground), dinner, baby bedtime
20:30-01:00: Review of lectures and reading textbook chapters

Friday -
07:30: Get up to take care of baby
10:00-13:45: Classes
13:30-17:00: Professor-led reviews (yes, I missed some, had to watch from archives again later)
17:30-20:00: Pick up son from day care, baby time (playground), dinner, baby bedtime
20:00-01:00: Review of lectures and reading textbook chapters, lecture slides, etc (studying)

Saturday -
07:15: Get up to take care of baby
08:00: Babysitter shows up to take the baby so I can study. I go back to bed.
11:00-17:45: Review of lecture slides, lectures, reading textbooks, online practice quizzes. Lost a couple of hours to procrastination due to general tiredness and lack of judgement.
18:00-20:30: Baby time, dinner, baby bedtime, my dinner after
20:30-24:00: Review of lectures and reading textbook chapters again

Sunday -
07:30: Get up to take care of baby
09:30: Wife gets home from shift.
09:30-11:30: Family time
11:30-14:00: Last-minute panicked studying, lunch, and take my test. Did poorly, sadly.
14:30-16:00: Baby care so wife could nap
16:00-18:00: Rosh Hashanah dinner with in-laws
18:00-18:45: Baby care so wife could nap
18:45-19:30: Abortive attempt to attend med student charity group meeting - meeting was cancelled but I didn't get the word.
19:30-20:15: Helping with baby bedtime and writing this post.

As procrastinations go...

2009-09-04T04:24:31Z

I suppose writing software is one of the more productive ones.

You guys might prefer I wrote LJ posts, though ;).

Household remedy: Salad Dressing. Or: Not yo' cheese, flies.

2009-08-17T20:38:14Z

Plagued by drosophila, as is properly befitting one who studies genetics.

But it's getting old, especially when I want to eat my fresh mozzarella and balsamic vinegar in peace. Apparently and unsurprisingly the little buggers have a thing for fruit vinegars.

My solution, recipe-like in case you have the same problem:

Ingredients: A long, thin glass like a pilsner. Cheap fruit (e.g. Apple Cider) vinegar. Oil of any sort. A tupperware lid, if you're squeamish.

1) Fill your pilsner about two inches with the vinegar. Leave it out on the counter in a still room full of flies for a few hours.
2) Return. The flies will have preferentially congregated (read: swarmed!) on the inside of the glass.
3) Slowly cover the top of the glass with the tupperware lid (if you're squeamish) or your palm (if you're not).
4) Shake the glass vigorously up and down, using the vinegar to wash all of the flies within to the bottom of the glass. Sadly, flies swim, so this will contain but not kill them.
5) Quickly pour in a few drops of oil. This is the trick that kills the flies, since flies are heavier than oil but lighter than water (and can't breathe in oil).

Voila! Fewer flies... and a bit of crunchy salad dressing, if you're really low on protein.

Repeat until your fly problem is under control.

Variant (but I haven't tried this): Instead of the above, try leaving a glass or a dish of vinegar outside an open window - the theory being that the concentration of flies outside of your kitchen is much lower than the concentration of flies inside the kitchen, plus flies outside may fly away or be eaten, and you're thus osmotically pulling flies from the kitchen.

The military wants my (white-coated, graduated) body

2009-08-13T03:05:48Z

Uncle Sam will be happy to pay my medical fees, if only I'm willing to sign up for 4 years of military duty post-school (and pre-residency, I believe).

I've been told so at least half a dozen times by now. Something tells me doctors don't often join the military without heavy recruiting and incentives... :)

Day In the Life: Terminal and Ultimate

2009-08-12T01:58:25Z

A few days into med school. Geeky medical details are found in footnotes so as not to detract from the story.

The morning is uneventful - lectures on basic pathology(1) and on the role of genetics in medicine(2). I could tell you about the cool things I've learned from those, but there are many better resources out there for that sort of thing - those portions of my audience that really want to know will probably go look them up, and those that don't wouldn't enjoy being spoonfed medgeekpap anyway.

Suffice it to say that diseases aren't just caused by external or internal factors, they're caused by the interaction of the two. Also, epigenetics is damn cool and we have very little idea how it works. With the possible exception of Barr Bodies. And I'm not talking Roseanne here.

After lunch we had a patient presentation, our first chance to meet a real, live sick person... Well, meet might be an overstatement - we're a well-dressed, white-coated, overeager mob of nearly 200 people.

A hale and hearty man in early middle age comes to the stage, along with his doctor. He proceeds to tell us all about how he came to the hospital with a minor complaint, and about his wife and his three children, and about his fun job in intellectual pursuits. Then he proceeds on through the diagnostic process, talking about which doctors saw him and the tests they did... and then he tells us he was diagnosed with cancer. Did I say his doctor? I should have been more specific. He's on stage with his oncologist.

Ok, I think, I knew that was coming since Dr. X the oncologist is on stage with him. Now he'll tell us about how wonderful his treatment was, how hard it was but how great it was that his family stood by him, and how good he feels now that it's over and the tumor has been removed and he's recovered.

No such luck. It's esophageal cancer, which I was surprised to learn is nearly always fatal. He looks so good because he underwent experimental treatment in a research trial, which halted the cancer's progress long enough for him to take an extended break from chemotherapy. He's still got a death sentence hanging over his head... and the tumors have started to grow again. This is a gut punch for those of us in the audience - he looks fine, he should BE fine, right? Not with cancer growing in his liver, his lungs, his lymph nodes.

He's a dead man walking.

We all are, of course. It's just that his time left is so much less than anyone expected. Even so, he's chosen to spend a precious day telling us about his experience. Having never seen him before today, I'm wiping away tears along with his wife when they talk about how they shared the news of the cancer with their children.

And then, after we listen to him and he answers our questions, life goes on. For us.

In the afternoon, I am reminded forcibly about my own mortality in a much more enjoyable way - I re-encounter the limiting natures of asthma and chronic knee pain when I join a pick-up game of Ultimate Frisbee. I can still forearm huck a disc, but there's no way I can keep up with someone a decade my junior(5) and make sure he doesn't score multiple times upon our team. I feel a bit like I've let down my vibrant young teammates. I leave the game early due to the combined pressures of lack of oxygen and lack of time before running to pick up the boy from day care.

In the evening, I spend time with my wife and our son, and I'm reminded that there are rewards to no longer being 21.

--------------------

1 - When injured, cells lose potassium, influx calcium and sodium, swell, get fatty, lose energy (ATP), undergo nuclear condensation and enucleation, lose membrane integrity, and lose cytoskeletal-membrane connectivity. If your cell is lucky, the process can be reversed if it's only a matter of swelling, fattiness, and ion concentration/ATP issues. Once you get to the nuclear changes and membrane integrity levels, well, you're lucky if you can apoptose rather than simply necrosing and digesting your neighbors.

2 - Personalized medicine is a shibboleth(3) euphemism for genetics-based medicine.

3 - Cool word from ancient Hebrew. Look it up. It involves genocide and grains(4).

4 - Yes, I'm so geeky my footnotes have footnotes. See also footnote(4) for recursion.

5 - Pending current changes. I'm biking to school and exercising a lot with classmates. Perhaps I'll regain fighting trim. Also, I need to do more fighting to stay trim.

On a lighter note

2009-08-08T05:15:46Z

(possibly not work-safe due to general (fake) grossness and music)...

http://www.youtube.com/watch?v=8y8G4s1yxi0

Of symbols and ceremonies

2009-08-07T23:58:25Z

My white coat ceremony was last week. For those of you not in the know, the purpose of the white coat ceremony is to officially indoctrinate incoming medical students into the profession.

There is a line of thought that criticizes the white coat ceremony. The reasoning goes: if you are set apart as a different class than your patients, then your patients cannot truly ever be close to you. That extra distance, the width of a swatch of white polyester, is a means of proclaiming your power over everyone who comes into your office. It is as powerful as the whip or the yellow sleeve, and as harmful.

I believe that criticism is sometimes valid when applied to the white coat as worn when treating patients, but I also believe that here, at the beginning of our careers, the white coat is an important reminder to the new student. We have no power over patients until later - we have yet to learn the spells and potions.

At the ceremony, we are given a white coat and told "You are no longer of the people. You are of the elite. While you do not yet hold the skills to lead the way, you are now newly responsible. You must act as if you were already leaders. You must be discreet and above all, you must be trusted and trustworthy."

At the end of the ceremony, all of the doctors present are invited to reaffirm their Hippocratic Oath. The words roll around the auditorium, echoed from hundreds of mouths and blending into a community voice which speaks for those who have been here before. It is a prayer, a blessing, a benediction upon all who come to us garbed in gowns, hat in hand and hopes in heart.

I am not a religious man. I don't know what the true face of evil is. Is it selfishness? Is it sin? Is it repression of others to further your own beliefs? Despite my pristine new raiment, I'm no priest to be able to answer those questions.

All I can say is that here, in the presence of so many who have dedicated their lives to combat illness, I find at least one thing that I can point to and say "There. That is goodness. That is righteousness, as pure as it comes. That is, finally, my purpose too."

Warning: Change in tone

2009-08-07T04:43:32Z

Since the creation of this blog, I've been very careful about what and how I posted. I had coworkers reading it, and generally didn't feel that the minutiae of my day to day corporate life could be revealed - or, if they were revealed, that they'd be interesting.

Now, I'm in med school. I'm going to assume that my path toward being all fledged up as a doctor is indeed interesting to most, and I've no coworkers reading the blog. So, the tone's going to change a bit. I'm going to be more confessional, likely post more frequently, and give you more of my day-to-day doings. I'm going to still protect patient confidentiality though.

Hope this'll be a welcome change - give me feedback if you like :). Do you look forward to tales from medical school? Do you dread them? Is your friends list already cluttered enough?

Mission: First year pub crawl.

2009-08-07T04:27:22Z

Outcome: Successful. Intoxication induced. Embarrassment avoided. Contacts made, contacts reinforced.

Didn't -just- stand in the corner like an antisocial wallflower.

Out of the country

2009-07-06T15:08:00Z

Hey all - if you're looking for me in the next (roughly) two weeks, you won't find me. I'll be far, far aweh.

Last Day

2009-06-30T15:26:38Z

Today's my last day before voluntary unemployment. It'll be my first time in a decade that I'm not employed full time.

How very, very odd.

PS - anyone who wants to play lots of Diablo II in the last half of July, drop me a line ;)

On black magic...

2009-06-19T05:58:44Z

I am a firewall god. I can convince appliances to do things they were never meant to do. You probably don't want to ask for details unless you really care about the innards of iptables on a linux platform.

... Making the world safe from spammers, malware, and rootkits, one machine at a time.

Fun idea...

2009-06-16T04:36:35Z

People are always talking about how great the hydrogen economy will be, but it's inefficient to transport hydrogen, and current manufacturing techniques often make more pollution than they save (e.g. making hydrogen from methane rather than electrolysis).

It'd be pretty cool, though, if we had electrolysis stations throughout major cities, powered by this type of high-altitude wind farm: http://www.wired.com/wiredscience/2009/06/highaltitudewindpower/

You could generate hydrogen by electrolysis when the wind was blowing strongly, storing it for use when the wind was blowing only weakly. Convert back to electricity via fuel cells or burn in hydrogen powered cars...

Anyway, just dreaming. Enjoy!

Foot, meet mouth.

2009-06-14T03:05:31Z

Wife: I have to go get beautiful.
Me: Yeah, that's gonna take a while. (Thinking of all of the preparation we have to do to get ourselves and the baby ready so we can have a formal night on the town after dropping him off at the sitters)

IQ: 156 (at the age of six)
GPA: 4.0 (fudging and only looking at recent data)
Foot: Firmly inserted into mouth. Priceless.

It's a good thing I've a patient wife who knows me well.

Back in contact

2009-03-06T18:24:20Z

Brief summary of events: Several family members ill at once. Was not expecting to start my doctoring career on my own family and before actually starting med school.

Update

2009-02-26T02:53:40Z

Out of contact until further notice. Dealing with multiple stacked family emergencies.

hearth_spirit @ 2009-02-25T18:53:00

2009-02-25T23:57:33Z

Lousy: Having a respiratory virus.
Lousier: The whole family has one.
Lousier than that: And I threw out my back Monday morning, which has been in spasm ever since.
Lousier still: And my mother in law is so sick we had to take her into the hospital.
Lousier than that: Once we got her out of the hospital, our son was so sick -he- had to go into the hospital (literally, figent_figary was taking him into the ER at the same time I was retrieving her mother for her home).

The hospital room was impossible to sleep in, so while we're home again, figent_figary is absolutely exhausted - the stay literally made her sicker.

It's probably time to just dump liquid albuterol in the ventilation ducts. It'd do everyone good in the house, with the possible exception of the cats. And I'm not so sure about them. For all I know they're as allergic to us as we are to them.

I usually try to avoid publishing downer posts, but come ON, ye gods and little fishies, this has been one hell of a week. So far, everyone's surviving. But there's been at least twice when that was in doubt. Let's hope the luck holds and recovery is had all around.

Life in the household of the geeky and time-management-challenged

2009-02-23T21:31:10Z

"Team housework" is now a Google Calendar recurring event (MWF), with figent_figary invited.

Out of curiosity, a question for those of you, dear readers, who cohabitate. How do you ensure even distribution of household chores? Do you?

Separately, if applicable - do you find yourself tempted by or accidentally sliding into the "standard" societal models of one person (the female?) doing the lion's share of the work? I know that it's one of the things I constantly keep an eye on, though judging my success on that front is something I'd leave up to the opinions of my past & present fellow cohabs.

EDIT: The above may have been poorly phrased - I meant it as a survey rather than a plea for advice. Thanks for all of your suggestions/answers, though! :)

Concept

2009-01-29T22:55:19Z

On the left shoulder blade or left deltoid:

Monochrome, black and white only.

A serpent (2,3), wound around an upright sword (4), upon a shield (1), resting on an unfurled scroll.

Serpent for healing, sword for readiness and willingness to act, shield for defense of self and others, and scroll for the importance of learning and science. The left shoulder rather than the right to symbolize that even the weakest side must be strong enough to provide aid.

1 - Perhaps a buckler (http://upload.wikimedia.org/wikipedia/commons/d/d0/Buckler_b_(PSF).jpg), kite shield (http://eagleswords.com/library/KnightsTemplarArmorShield5.jpg) or heater shield.

2 - Singular. Aesculapius, not Hermes.

3 - Venomous or stylized generic. Harmless (garter) or constricting (boa) are inappropriate here.

4 - Cruciform. Simple, clean lines.

Comments?

Good news...

2009-01-29T14:48:33Z

I've been working over the last 3-4 years to apply to medical school. Last night, at 10 PM, I got an email indicating that my application was successful. To one of the top schools in the entire country! It's ranked significantly higher than #20, but in the interests of preserving anonymity for local friends... I'll not mention which one. The astute or knowledgeable may guess.

It won't involve me moving, and my commute will be walkable.

In any case - I guess I know what I'll be doing in August! Now to make sure I fulfill my obligations to my current employer. :)

hearth_spirit @ 2009-01-22T11:19:00

2009-01-22T16:28:19Z

The president has just signed four executive orders:

1) Close Guantanamo Bay within a year.

2) No more torture - only interrogations consistent with the army field manuals.

3) Sets up a committee to figure out how to deal with "detainees". (Attempts to ) grant them habeas corpus and to avoid extraordinary rendition.

4) (specific details about Khalid al-Mari's case before the supreme court)

"The message that we're sending around the world is that the United States intends to prosecute the ongoing struggle against violence and terrorism, and we're going to do so vigilantly, effectively, and in a manner consistent with our values and ideals." ... "we are not going to continue with a false choice between our safety and our ideals."

Barock on! Poor guy looks like he isn't getting much sleep, though. And I didn't know he was left-handed! Also, he's the only one in the CNN feed who's not an old white man (excepting the female aid passing him papers).