U-TEACH (Final)

At 7am the next day (Friday), I stopped by to see my U-TEACH mom. Unfortunately, she was painfully frustrated because she was still only dilated 3cm, though her contractions were more frequent and regular. She convinced me to go to class, where I explained to everyone who knew about U-TEACH that she had not yet delivered. I had a solid block of class from 8-3, but at around 2:30pm, I got a message that she had just started pushing. I ducked out of my elective and headed over to L&D.

When I got there, there was a lot of hustle and bustle. The nurses were busy putting on monitors, and the mother was getting contractions every few minutes. I was put on right leg duty. With an epidural, the patient has to stay in bed. However, it helps the patient push if she is in a squatting position, so we try to hold her legs up to simulate squatting. She was doing well on her pushing, 10 seconds duration for three times with each contraction. In between contractions, she was getting rest, talking a bit, and taking ice chips.

This went on for several hours. It was painful to watch. Every time they yelled push, I could feel myself pushing too. The nurses tried being cheerleaders and drill sergeants, but she was just not progressing very quickly. Part of it was that the epidural anesthesia made it hard for her to feel her perineum. It was painful to watch; you could really tell she was putting everything into it.

After nearly three hours, the anesthesiologist came to present her options. He did a very good job with it. He said that she was doing a great job, slowly, but progressing, and that she could continue pushing. He also said an option was a C-section, but he did not think that was appropriate at the time. That left an assist, either by suction or forceps. In this case, the mother would be doing all the work; she would be pushing during the contractions, but the obstetrician would use either a suction or forceps to help guide the baby out. The mother opted for the forceps assist.

At that point, the decision was made to bring her into an OR. This was precautionary; they didn't expect anything to happen, but they wanted to be ready for an emergency C-section if necessary. While this was naturally a little scary, things transitioned smoothly. The husband and I geared up in the big blue bunny suits, complete with cap and shoe covers. In the OR, things moved incredibly quickly. Everyone seemed to be doing something. People materialized out of nowhere, and there were over 10 people in the room, with the anesthesiologist and resident, the pediatricians, the obstetrician, the nurses. I tried my best not to get in anyone's way while trying to see what was going on. I helped comfort the mother and made sure the father was doing okay (since he was apprehensive about blood).

The anesthesiologist told me to go see when the baby was just crowning. It is an amazing sight. I can't really describe it, but after the 30 or so hours since the first contraction, everyone was waiting for this moment. The baby squeezed out, amazingly beautiful, and once he came out, half a dozen things happened. Someone clamped the umbilical cord, caught and measured the placenta, puffed something in the baby's mouth, and handed the baby off to the pediatricians. When the baby boy started bawling, I could feel everyone in the room breathe a sigh of relief and gratitude. The father did not want to cut the cord, so he asked me to do it. It was both really something and not a big deal (especially after anatomy). I was not sure if it was my place to do it, but it was their request. The pediatricians then cleaned off the baby, checked him from head to toe, and handed him back to the parents.

The mother began sobbing and talking to the baby, so incredibly happy to have undergone this ordeal successfully. It was one of the happiest moments I've felt. I wouldn't have given up this experience for anything. The medical team dispersed as quickly as they had appeared, and we retired back to the delivery room. Both the mother and baby are healthy and doing well. I've been visiting them nearly every day since, and I think this has been one of the best opportunities I've had.

U-TEACH (Continued)

Last Thursday, my U-TEACH patient was scheduled for a fetal monitoring in the morning. It was actually her due date, and so when I met her she told me contractions had begun late last night. I was quite surprised. The contractions were variable in spacing, and though they caught her breath, she was able to deal with them fairly well. She was just 2cm dilated, and they told her to walk around for a bit before checking into Labor and Delivery.

All day I was pretty anxious, making it hard to focus in class. It was unfortunately a very packed day with FPC and everything. Finally, I got a text message from them saying that they would check into L&D in the evening. After dinner, I went over to meet them. L&D was very busy that evening, and it took us a while to be triaged. The contractions were a little closer together, though still not regular. We finally got put into a delivery room. These rooms are really nice! They're quite big, with hardwood floors, a beautiful view of the city, a private bathroom with shower, a TV, a refrigerator, and a couch. Of course, they have the delivery bed, the pediatric exam table, and all the medical equipment that might be necessary.

In any case, I stayed there for a few hours to keep the mother-to-be and husband company. After a bit, I stopped at home to prepare for classes the next day. I came back about an hour later, at 1am. Unfortunately, she had only dilated to 3cm. I met most of the team: the anesthesiologist, the obstetrician, the nurses. They were wonderful people, who really took the time to talk to the patient, get to know her, and act as resources. Furthermore, they were great about introducing themselves to me, talking to me about the program, and explaining some of the medical side of things. Finally, after over 24 hours since the contractions began, the mother decided she needed some pain relief. The anesthesiologist came in to do the epidural. Even though we called him at 2am or so, he was very cheery. The procedure itself was technically impressive - imagine palpating for specific spinal processes on a patient, using a large bore needle to enter the epidural space, and finally thread in a catheter. He tested it by giving a bolus of epinephrine and watching the heart rate go up. Everything went smoothly, and the mother gave the biggest sigh of relief. She and the husband decided to go to sleep, and I headed back to catch a few hours of rest before 8am classes the next day

Hi! I'm new here.

One of the electives I took last quarter was U-TEACH, "A Unique Teaching Experience About Childbirth and Health." The elective is way better than its acronym suggests. It's a perinatal elective which has a didactic and an experiential component. The didactic lecture series happened last quarter where we learned about different issues in pregnancy and childbirth. In the experiential part of the class, we get paired up with an expectant mother and family. In order to get a longitudinal patient perspective, we attend prenatal appointments, act as a liaison for the patient and resources, and attend the childbirth. It's a really great program.

Less than a month ago, U-TEACH contacted me saying that they had a mom who was eager to have a student, but was due in just a few weeks. I was paired up with her, and everything since then has been an amazing experience. We met early one morning and I got to learn about her family, expectations about pregnancy and childbirth, and her medical history. I also got to know her interests, jobs, and hobbies. It was really good developing such a secure relationship with a patient. She was incredibly nice, extremely open, and great about helping me get as much out of this experience as I could.

I was able to attend two fetal monitoring sessions. They were really interesting. The mother, the husband, and the nurses were so kind to me. Ultrasounds takes a while to learn to read. Although I have trouble seeing finer structures, it's really cool to make out the spine or arms or head of the baby. After that, they monitor the fetal heart beat and movements.

The title of this post is from a super cute baby outfit the couple bought. It was an infant "onesie" with the words, "Hi! I'm new here!" and a picture of the globe. Very adorable.

A Theory of Justice

Pulmonary block was fascinating and still manageable, a good combination. It really eased us back in after break. Most of the concepts having to do with the lung are somewhat intuitive, and though equations can get a little intimidating, as a whole, it's a pretty simple organ. I did learn a good deal from the block though. I feel a little more confident reading chest X-rays; though I still have some sort of veil of ignorance regarding most of radiology, I think I'm making progress in deciphering scans.

One of the interesting aspects of pulmonary medicine is occupational and environmental exposures. I hadn't really put that much thought into these diseases. For example, one can get hypersensitivity pneumonitis from the strangest things: avian proteins ("Bird Breeder's Lung"), mold ("Farmer's Lung"), aspergillus ("Malt Worker's Lung"), mycobacterium ("Hot Tub Lung"). It's strange how many different everyday exposures could cause lung damage in those that are susceptible to the antigen. Everyone knows about asbestos, but who would have thought beryllium could cause a disease looking like sarcoidosis?

We also had several physiology labs and a patient simulator lab. The physiology labs were pretty easy; we looked at the volumes of normal breathing, the gases in expired air, and the effect of breathing in lots of CO2 or little O2. And while a lot of people dislike the patient simulator (since it takes a while to get to San Francisco General Hospital), I enjoyed it. I like applying what I know to a (somewhat) real patient.

We also touched a little upon tuberculosis, an international health problem. I was shocked to find out nearly 1/3 of the world's population is infected with TB. Nearly all only have latent TB, but 10% of those with latent TB will progress to active TB, with greatly increasing rates in the immunocompromised. I just think that learning about international diseases is extremely important since the "ecology" of diseases outside the U.S. differs so much from that of the U.S.

In any case, we just finished the pulmonary section of Organs block. Renal is next. As a side note, the title of this blog and the "veil of ignorance" (first paragraph) refer to American philosopher John Rawls. Rales (which can be pronounced "rawls") are lung crackles that you hear on auscultation if there is fluid in the alveoli. I apologize for the pun.

Asthma

Our asthma pharmacology lecture was given by Dr. Boushey, Chief of Allergy and Immunology. Surprisingly, this was the lecture I attended a full year ago when I came to interview at UCSF. I think he's a really awesome lecturer; he has the sort of presence that commands the room. In any case, the projector wasn't working, yet he was able to deliver a really impressive lecture. During the class, he also demonstrated the proper methods of taking different types of inhalers, which I found fascinating. I wonder whether those inhalers were really loaded with albuterol (since you can take quite a few puffs without consequence). He must have tried out four or five different inhalers through the lecture.

When he described environmental factors that exacerbate asthma, he showed this picture:


We also had a lecture by a pathologist describing asthma. His first slide was a black blank slide. He then said, "This is an important slide, illustrating how much most general pathologists know about asthma." It was quite amusing.

Excerpt from Class

One of the course coordinators was showing us some chest X-rays last Friday. In response to "Where is the pneumothorax?" she said, "To the left, to the left." When she heard me chortle, she replied, "Me and Beyonce...we're tight."

Poem

DEATH be not proud, though some have called thee
Mighty and dreadfull, for, thou art not so,
For, those, whom thou think'st, thou dost overthrow,
Die not, poore death, nor yet canst thou kill me.
From rest and sleepe, which but thy pictures bee,	5
Much pleasure, then from thee, much more must flow,
And soonest our best men with thee doe goe,
Rest of their bones, and soules deliverie.
Thou art slave to Fate, Chance, kings, and desperate men,
And dost with poyson, warre, and sicknesse dwell,	10
And poppie, or charmes can make us sleepe as well,
And better then thy stroake; why swell'st thou then;
One short sleepe past, wee wake eternally,
And death shall be no more; death, thou shalt die.

John Donne, Sonnet 72, excerpted from http://www.bartleby.com/105/72.html

The Spirit Catches You and You Fall Down

It seems like every medical student reads this book. The Spirit Catches You and You Fall Down by Anne Fadiman is a non-fiction cultural exploration, describing a Hmong child with severe epilepsy. It's a pretty fascinating book that captures the clash of cultures when Western medicine confronts Hmong ideas about health, sickness, and spirituality.

Most medical students read this book to get a better perspective of the culture of medicine and its shortcomings. Indeed, miscommunication, lack of cultural understanding, and differences in perspective lead to tragedy in the life of this child. The book also gives clues to which barriers can be overcome with training in cultural competency, and which barriers may be, for the most part, unsurmountable. However, I also found a great value in this book in learning about the Hmong, often refugee families from Laos. I knew nothing of their history, their beliefs, their values. This piece of literary journalism really helped me gain a better understanding of the places (not just physical) where patients can travel from to get treatment at a hospital.

There are some poignant moments, some breathtaking moments, some dramatic moments, and some heartfelt moments in this book. I recommend it to anyone with a desire to learn about these issues, which have become more and more important in the delivery of good health care.

What Good is an MD?

In one of my electives, the speaker discussed all the different career paths you can take with an MD. That was surprisingly helpful. It's a bit alarming how little we know about the degree before we commit ourselves to at least 7 years of training. I'm sure many people know most of this information, but I found a quick run-through useful, especially now that I'm halfway through my first year. This is intended to help any other med students who run into this blog.

Most M.D.'s practice medicine. Not shocking. You can practice medicine locally in managed care, private practice, small groups, or with government (NHSC - national health service corps, military). You can also practice medicine internationally with NGO's or governmental organizations. Other doctors go into health care administration. They work with HMO's, managed care, hospitals, or government (Department of Public Health, NIH, CDC). An MD can help you get into industry or business, especially in pharmaceuticals, biotech, and consulting (that's where you can make the big bucks). Lastly, doctors can go into academia in research or clinical tracks, focusing on teaching, research, practice, administration, and community service. Other paths include law. There are really many different things to do with an MD.

High Altitude Medicine

We had a guest lecture by Dr. Gianotti from Stanford on high altitude pulmonary physiology. Due to low barometric pressures at higher altitudes, mountain climbers (and tourists) often face medical issues like acute mountain sickness, high altitude pulmonary edema, and high altitude cerebral edema. The science and medicine behind all these conditions are pretty fascinating and make a lot of sense, but probably outside the scope of this blog.

About ten minutes into the talk, it suddenly occurred to me I had heard the professor's stories and seen his slides before. It turns out, he gave the same talk to the human physiology class I took at Stanford. Amazing, huh? He's an expert on this topic, having staffed clinics in the Himalayas and been the physician for ambitious climbing trips. His stories are certainly poignant and awe-inspiring. He is a great supporter of the locals (a team of ten climbers had to hire 300 local people to carry their equipment, including two simply to carry the money to pay all of the porters on a daily basis - it's crazy). His pictures are beautiful.

Turf

The term "turf" is sometimes used in medical settings, referring to the act of sending a patient to another service. For example, a surgeon might be preparing for an elective surgery on a patient, only to find that the patient has a fever. He might then turf the patient to internal medicine, where they will take care of the presumed infection first. I might blog in the future about these odd hospital terms.

In any case, today I will be lazy and turf the blog to a post by one of my classmates Stephanie. Her blog is very insightful, literary, and entertaining. Since it also describes the first year of medical school, it might be a good counterpoint to this blog. It's certainly worthwhile reading and deserves many praises, but I will direct you to a post that I found particularly entertaining about the city of San Francisco.
http://ucsfsynapsemed1.blogspot.com/2007/01/my-secret-crush-on-san-francisco.html
In that San Francisco post, I especially like the pun in, "Of course, [...] San Francisco has her faults..."

Stephanie's blog is here: http://ucsfsynapsemed1.blogspot.com/

Giraffes? Giraffes!

"Mrs. Dursley was thin and blonde and had nearly twice the usual amount of neck, which came in very useful as she spent so much of her time craning over garden fences, spying on the neighbours." (Harry Potter and the Philosopher’s Stone)

A question came up in physiology lab: What happens to animals like giraffes, trumpeter swans, and Petunia Dursley who have a lot of anatomic dead space due to long necks?

So for those who don't have a lung physiology background, gas exchange (to put oxygen into your blood and remove carbon dioxide) occurs at the boundary of alveoli (air sacs) and capillaries (blood vessels) in the lungs. Dead space refers to parts of the respiratory system where there is ventilation (air coming in) but no perfusion (no blood). Everyone has anatomic dead space - this refers to things like your nose, mouth, trachea (windpipe). You ventilate these structures when you breathe, but there are no alveoli or gas exchange capillary beds there. Dead space represents air that you work to breathe in, which does not participate in oxygenating your blood. Giraffes have a lot of dead space because of their long necks - they must work to bring in air, but air sitting in the neck does not contribute to gas exchange.

Well, it turns out that giraffes compensate for increased dead space by having incredibly large lungs - the San Diego Zoo website says giraffe lungs can hold 55 liters of air (our lungs hold maybe 6 liters of air). The giraffe also breathes really slowly, allowing it to move lots of air in and out with each breath (large tidal volumes). It turns out that the dead space/tidal volume ratio is 0.34, comparable to humans. So giraffes, despite having ridiculously long necks, are able to efficiently take in oxygen and get rid of carbon dioxide.

For those thinking about comparative anatomy, you might also wonder how giraffe hearts can pump blood all the way up to their brains. Interesting stuff.

Physicians Should Be Humble

Here's a sketch of a (philosophy) argument.
1. Medicine is oriented against death.
2. Death is inevitable.
3. Medicine cannot "win" if it is opposed to something inevitable.
Therefore, physicians as practitioners of medicine should be humble and acknowledge the limits of their abilities.

Now, I think this argument is a terrible one; it may not be valid without all the steps fleshed out, and I certainly don't think it is sound. I disagree with the first premise. And indeed, anyone who has thought about issues of end-of-life care, the purpose of medicine, or the humanistic "healer's art" would vehemently argue that the relationship between medicine and death is obscure. Indeed, medical school has few lectures on death, dying, and how to deal with it. Death is not the subject of this post, but it is something I have thought a good deal about, and perhaps something that will come out more in these posts as I collect my thoughts.

I will say that though death is inevitable, medicine has many different goals and purposes existing in various relationships with the concept of death. The fact that doctors cannot stop you or me from someday dying does not make medicine futile, worthless, impotent, or hopeless. However, I do agree with the conclusion. Physicians must be humble. There are limits to what we know and what we can do about the human body and disease. We must acknowledge them, but we must also realize that the purview of medicine extends far beyond combating death.

Textbooks

The second year students always tell us not to buy any of the textbooks. For each of our courses, we get a syllabus (like a course reader) which is very comprehensive for all the lectures. The syllabi are written by the lecturers, and knowing all the information in the syllabi is sufficient for acing all the exams. We just don't have time to do supplementary readings in textbooks.

It's a pretty interesting system. The syllabi are directed to our learning objectives and tailored specifically to our curriculum. It's very useful to have this concordance between our lectures and our reading. However, I also think there are problems with this system. Since they are not textbooks, the syllabi have a higher frequency of mistakes in them. They aren't as useful as textbooks as a reference. But all things considered, I think it's a good system to use these tailored syllabi primarily and textbooks supplementary.

Not Waving, But Drowning

We've started the pulmonary segment of the Organs block, so we have a little over three weeks on the lungs. The lungs are a bit easier than the heart (no electrical activity), and they're vitally important, so this should be good. We've had some anatomy, histology, and basic ventilation/perfusion lectures. Our first case was a near-drowning. It's been a little rough getting back to the school schedule after a really relaxing break, and I thought of this poem by Stevie Smith (1957). I apologize, it's a bit dark.

"Not Waving, But Drowning"

Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving, but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning.

Rachel Remen

One of the electives offered this quarter is called "The Healer's Art" and was developed by Rachel Remen, a doctor for 45 years, a teacher for almost as long, and a patient for longer. She is also the author of this bestseller, which I have not yet read. On Wednesday, she gave a lecture entitled "Being Good Medicine: Realizing your personal power to make a difference."

It was an excellent, moving, and inspirational lecture. She told many heartfelt stories of the art of medicine - using one's humanistic side to heal a patient that science cannot cure. She emphasized the idea that doctors can contribute to a person's health even if their disease is incurable. Physicians need to approach patients as people not as diseases, a simple idea that often gets obscured during medical training when students get very excited about seeing rare illnesses. She shared some personal stories of how members of the health care team contributed more to her well-being by talking to her as a human being than by procedures or drugs.

Her talk really convinced me that the humanistic side of medicine is just as important as the scientific side. You have to use all your resources to heal a patient, not just treat or cure him. Many of us have fundamental skills that we gained before medical school that will help us in helping patients.

For an added plus, she mentioned the Greek God of Medicine Asclepius, for which this site is named. That was impressive.

I don't think, though, I will take the elective because it doesn't fit perfectly into my schedule. It seems like an excellent elective for thinking about many of these issues - "honoring loss," "the care of the soul," "discovering and nurturing your wholeness." Indeed, this is a course mirrored in many different medical schools, and it has been successful for many years. Though I probably won't take it this year, I am welcome to any discussion or interest on any of these related topics.

Hemoglobin

I think I've learned about hemoglobin in at least half a dozen classes. All bio classes (and even some chemistry ones) seem to find some way to sneak it in. They even had a crystal structure in today's lecture. Ah, well. At least it was a lot more clinical than hemoglobin discussions usually are.

2007

With the New Year, I tend to re-evaluate the things I spend time on, including this blog. Recently, I have become somewhat interested in reading medical blogs. There are a lot of very good ones out there, with entertaining stories, drama, clinical puzzles, and great images. Then, I began wondering what I am doing with this blog. I don't have the experience or knowledge to write about fascinating clinical cases. I don't have X-rays to post or MRI's to interpret. I don't even know how to interpret X-rays and MRI's. My posts don't have great wit or humor or insight. So what am I doing here?

The primary goal of these writings is and has always been to keep a record of my first year of medical school so that when I am old and gray, I will have something to read. I want a somewhat well-written, formal (or at least punctuated and capitalized), regular blog. I think I am somewhat accomplishing those two objectives. I'll try not to let my frequency lag as things get busier and motivation starts dropping.

Beyond that, however, I hope to maintain an entertaining account of events in my life. I try to keep posts at a readable length. I suppose one New Year's resolution will be to add images to the blog. Believe it or not, I began using blogger about six years ago and have maintained this old school text-only format. Times change, however, so I'll begin throwing pictures around.

To anyone who wandered randomly onto this blog, it's a peek into the mind and life of a constantly befuddled, constantly learning first year medical student.