Lucid Dreams

Lucid dreaming is an interesting phenomenon in which you are aware that you're dreaming. In fact, during those dreams, you can exert conscious control over what happens in the dream including doing things that are physically impossible. Once in a while, I find myself in a lucid dream, and I sometimes wonder how I realized that. Sometimes I can gather clues in a dream like reading something, looking away, and reading it again (it often changes) or forcing myself to attempt to breathe underwater. Once I'm in a lucid dream, I find myself able to do things like escape by hiding in the ground or jumping atop buildings. Lucid dreams are really fascinating things. I sometimes also dream that I'm waking up and go through the motions of getting ready in the morning. When I actually do wake up, I'm usually woozy enough to find the deja vu very jarring. Anyway, all this weirdness with dreaming makes me think a lot about the nature of consciousness and experience.

Micro Lab II

The other cool thing we do in lab is identification of unknowns. We are given a clinical case and asked to generate a microbiological differential. Then we are given some sort of sample - a throat swab, a blood culture - to run our experiments and identify the microbe. Some of the time it feels artificial because it's obvious from the clinical case or the sample we get what we're supposed to learn. But at the end of this block, we'll get to plan out a wet case in which we design and execute everything. We get an unknown case, decide what kind of culture we'd like (blood, urine, throat, stool, CSF, cervix, sputum, other) and what kind of laboratory tests we want to run (CBC, clotting times, chem panel, U/A, etc.). They give us information on how much everything costs too. We then have to work up the patient and conduct all the tests to secure a diagnosis. I think that's really cool.

Micro Lab I

For the microbiology section of I3, we have a regular lab every MWF to learn basic techniques in culturing and identifying organisms. It's pretty cool and although it's not super well organized, it's a nice change of pace. We do basic things like Gram stains, pure cultures, TSI slants, and antibiotic resistance testing. A few interesting experiments involved identifying normal flora in ourselves. We did throat cultures on each other and stool cultures on ourselves. I really like the lab environment; I like planning and running experiments (albeit short and simple ones). Most of the stuff is very straightforward; if we see gram+ cocci in clusters, then we should run a coagulase test; if it's in chains, we should look at the hemolysis pattern. But still, there's something to be said about the process of investigation. The end goal of the lab is to teach us how laboratory tests are done, when we should order them, and what sorts of results we can expect.

Bugs and Drugs

It's the part of med school that everyone dreads. We're sludging through the parade of bacteria, fungi, viruses, and parasites. It's a lot of memorization. No particular fact or bug is too hard to learn, but there are so many that it feels quite overwhelming. How does it Gram stain? Does it ferment lactose or live in bile? Does it have catalase? Exotoxins? Pili? What kind of conditions do you need to culture it? What does it look like? What diseases does it cause?

A lot of times, things don't make sense. For example, Haemophilus influenzae is a gram negative rod that causes meningitis, bacteremia, sinusitis, pneumonia, even otitis media - pretty much everything except the flu (which is of course caused by a virus). It was originally thought to be the causative agent of the flu, but no one bothered to change the name after the confusion got cleared up. On the other hand, Alexandre Yersin named the causative agent of the plague Pasteurella pestis after his mentor, but after he died, they managed to change the bug to Yersinia pestis.

To go along with all these bacteria, we have many different antimicrobials to learn along with the mechanism of action, the clinical use, the metabolism and pharmacokinetics, the toxicities. In any case, we've gotten through the bacteria; we're just starting fungi and viruses now. We had an exam on Monday and another one is coming up in a little over a week.

Image is from adoptamicrobe.blogspot.com - Clostridium perfringens is the causative agent of gas gangrene.

Patent Law

This is something I find interesting and ethically controversial yet know little about. From what I understand, stem cell technology has been patented by the Wisconsin Alumni Research Foundation, a nonprofit technology transfer office that acts as a funding source for the University of Wisconsin. These patents include the methods for isolating or purifying primate and human embryonic stem cells. In order to do anything with embryonic stem cells (no matter how they are derived), you have to have permission from the U. of Wisconsin.

This really limits research involving embryonic stem cells. Luckily, academic nonprofit institutions are much less impeded than commercial entities (whose licenses cost anywhere from $75,000 to $400,000 a year). Indeed, companies like Invitrogen are pursuing embryonic stem cell research abroad because the patent's jurisdiction is limited to the U.S. But still, the U. of Wisconsin has made hundreds of millions of dollars from this one technology. They have a team of something like 32 lawyers defending these patents.

There are several issues of concern here. First, what are the parameters for patenting a scientific methodology? (What if someone had tried to patent antibodies?) What are the costs and benefits to the public? Is the cost in impeding commercial research in a field worth the security offered to investigators in disclosing scientific ideas and discoveries? Also, are there certain values or principles that underlie a decision by an academic scientist to patent research rather than publish it?

Impersonating a First Year

Like many first years, I attended a few "Meet and Greet" events for internal medicine and surgery. I'm also taking "Intro to Internal Medicine" and "Pediatrics Subspecialties." It's refreshing going to these talks; it reminds me of all the exciting possibilities in medicine. I feel like lately second years have been so bogged down with everything that we lose perspective. At these talks and electives, a wide range of attendings, fellows, and residents are enthusiastic to share with us what they love about their jobs. I also learn a lot, especially about pediatric specialties which we've had less exposure to. I really feel like the resources at this school are tremendous.

Mnemonic

"There is a great mnemonic to remember the organisms that cause invasive enterocolitis. If you remember what I'm going to tell you, you won't have any trouble identifying the bugs that could be responsible when that patient rolls into the dark ER at 3 in the morning your intern year. You'll be glad you learned the easy mantra that I am teaching you today. That mnemonic is: Shigella, Salmonella, Campylobacter" (Professor Ganem). I was quite amused.

Bad Excuses

A bad excuse when generating a differential for a case is "Oh it can't be cancer since we haven't learned about that" or "We're in the infection block; it has to be something bacterial, and we can rule out pulmonary embolism." It disappoints me when I hear my classmates say something that artificial. We're beginning to hear this a lot, but our small group leader said, "Make mistakes now, it's a luxury you won't have for long. Here there is no penalty, and in fact I want you to make mistakes as it's a teachable moment. Next year, you'll be caring for real patients and you'll be expected to get everything right. And three years from now as a lone intern on a dark ward at 3 in the morning, you can't afford to make a mistake when deciding whether to prescribe the antibiotic or not."

Taking a Sexual History

Our patient care course this year started off with taking the sexual history, an important yet sensitive topic. I'm not sure what the best way to teach or learn this is. I feel that lecture was somewhat mundane in reviewing points like "be sensitive and nonjudgmental," "respect cultural differences," and things like that. It's not as if we keep suspended in our minds the list of do's and don'ts as we interview a patient with pelvic inflammatory disease. But in small group, we watched some video clips of complicated patient interviews, and I realized there was a lot more to this topic than I first thought. What do you do if as a physician, you discover your patient is having an affair which puts his health and his wife's health at risk? You have to respect confidentiality and this private information comes only because the patient trusts you. Yet you have an obligation to protect the health of others. What do you do if a patient starts making overt gestures of attraction to you? How do you deal with a patient who has no problems describing wild and unimaginable sexual activity that embarrasses you? What about the kid who may be attracted to the same gender but living in a social situation that prohibits it? There are a lot of tough situations that physicians find themselves in, and I'm not sure I'll be the right person to handle these things.

Artemis

One of the key enzymes in lymphocyte V(D)J Recombination is called Artemis. Although I sometimes dislike random names for proteins and biological molecules (I never liked "Toll" or "Hedgehog"), I thought this was a cool title. Artemis, daughter of Zeus and Leto, is the maiden of the hunt (you can see the quiver on her back). She's often associated with the moon (her brother Apollo is associated with the sun). I guess Artemis really has very little to do with nuclease activity at hairpin turns, but I happen to like it.

The image is "Diana of Versailles" also known as "Artemis with a Hind" from the Louvre. It is from Wikipedia and in the public domain.

"The only people I know who succeed at everything they undertake are those who have been timid in setting their goals." - John Hennessy, Stanford Convocation 2007.

Anatomy Lab

We got a chance to go back into anatomy lab to practice some procedures which was awesome. I really enjoyed it! We got to do a knee aspiration and a shoulder injection (both into the glenohumeral joint and the subacromial space). That was really fun. It was good review of the joints and correlated with the curriculum in learning about septic arthritis. I just really enjoyed pretending to do procedures on cadavers and being successful after many pokes. It actually made me feel somewhat like a doctor.

Image source: emedx.com

Textbooks

For the immunology part of this course, the required textbook was written by one of the faculty teaching the course. The book was fantastic in that it covered everything exactly to the level of detail that we needed to know for this course. It pretty much replaced our usual syllabus, and in terms of information relevant to the test, it had a high signal-to-noise ratio. However, I didn't like the book as much as my classmates did. It was an incredibly simple primer, and it left out some of the most exciting details of immunology. Granted we didn't have to know that, but I usually expect textbooks to have more depth than required for those interested in it. I also started wondering about the role a faculty-written book plays in the curriculum that the faculty person teaches. It's a double edged sword, really. The textbook will emphasize those points the professor thinks are salient, but it may not objectively be the best textbook out there.

New Kids on the Block

I wanted to write something about the first years, but now I'm not sure what. I guess it's kind of refreshing and reminding to see them mingling together, so eager to explore, newly inducted into medicine. It's hard to imagine that just a year ago, I felt the same. Now, second years carry a more grim demeanor, burdened by the looming horizon of Boards, our original energy tarnished by the reality that despite being an immeasurably rewarding path, it is a long and trying one.

The image is the Rod of Asclepius.

Moving Deck Chairs on the Titanic

http://indexed.blogspot.com/2007/08/moneys-in-treatment-not-cure.html

I found that amusing.

Immunology

Our first two and a half weeks were a whirlwind of immunology and rheumatology. I was quite impressed; we covered the salient points of immunology in just a week. It's interesting learning this in a medical context; we learn some very specific details like NADPH oxidase because it plays a role in chronic granulomatous disease, yet we leave out other details like how RAG-1 and RAG-2 mediate VDJ recombination since the mechanism isn't important to physicians. When I took an immunology course at Stanford, we spent hours studying recombination signal sequences and hairpin loops and terminal deoxynucleotidyl transferase because the experiments were so elegant and the machinery so fascinating. I'm glad, though, that we focused more on clinical stuff as I knew very little about that. We read some journal articles too, which was good. Immunology is an interesting field because it has such a steep learning curve with figuring out the language and jargon, but once you begin feeling your way around, you realize how much and how little we know about it.

We also learned a few interesting rheumatologic diseases: SLE, OA, RA, gout, the spondyloarthropathies. We did all the vasculitis diseases in an hour which was sort of ridiculous. Rheumatology is interesting in many ways to me: it involves immunology gone awry, multiple organ systems, and diagnosis from history and physical. But unfortunately, joints simply don't fascinate me.

Our exam was yesterday, and it was all short answers. It reminded me a lot of undergrad tests. I wore my "It's not lupus" shirt, but unfortunately, one test question was most definitely lupus. Ah, well.

September 11

A sixth circling of rubble and dreams, and for the first time, I have heard a whisper of contest. When can we move on? Five words send my sacrosanct heart stumbling in epiphany. Are we stricken with inertia, bound like Greek Gods to orbit a fiery luminescence of the past, one whose lightyears of tragedy reflect and refract through the small prisms of our minds, only finding the beat frequency one single day of the year? Who or what shackles us with rank tradition, rationalizes those waxy burns on our fingers, allows us to entertain this Medusa? For if we do not know why we do it, then that Gorgon head revels in our paraplegic pleading, our impotent prayer, fuel-less and futile. Verbalize it. Because of someone you knew, a symbol you love, a security you lost? Because of anger? Sorrow? Vengeance? Because it is simply right? For justice? In remembrance and honor? Tell me. Because if we've lost cause, then it is time to come back inside, put piety on the hat stand, hang the cloak of duty for another day's resolve because I hate to admit it, but you will tap that well again and it best not be siphoned for an empty gourd. But if you carry a shell harboring reason, carry on. No whisper is unheard.

9/11

O beautiful, for spacious skies,
For amber waves of grain,
For purple mountain majesties
Above the fruited plain!
America! America!
God shed His grace on thee,
And crown thy good with brotherhood,
From sea to shining sea.
-Katharine Lee Bates, "America the Beautiful"

MS2

Second year started two weeks ago, and we really hit the ground running with immunology; our first exam is coming up this week. Though I am not ready at all for school (it still feels like summer), it's nice to see everyone again and hear about the adventurous things my classmates have done. The first day, they organized a breakfast for us so we could socialize. I really enjoyed catching up with people; I was really surprised with the number that traveled abroad to do projects in South America, Europe, India, and other amazing places. Indeed, it was probably the last summer we'll have in a while. Though its also interesting to me that this will be the last year I spend most of my time in a lecture hall.

Lightwand

Over the summer, I got the chance to trail an anesthesiologist in the OR. It was a really cool experience for several reasons. The resident wanted to learn lightwand intubation, a technique the attending was particularly good at teaching. In normal intubation, a laryngoscope is used to visualize the tube passing through the vocal cords. Instead, the lightwand is a device with a bright LED at the end; it's a blind intubation that does not require direct visualization of the vocal cords. However, the light allows you to see if you're correctly in the trachea (as opposed to the esophagus). It's similar to newer fiber optic scopes; these blind techniques decrease dental trauma and help in tough intubations (for example, bleeding).

Also, I got to put in my first IV! It was really exciting. The patient was already anesthetized through one IV, and the attending asked if I wanted to put in the second. Though it took two tries and was nerve racking, it was quite an experience. The other silly thing I got to do was "draw and push." It was really fun even though it was simply drawing medications into a syringe and pushing them into the IV. We of course reviewed pharmacology and physiology. I even calculated an A-a gradient. It was really cool, and both the attending and resident were fantastic.

Image from airwaycarnival.com

Summer in SF

I was going to write a little about summer in San Francisco because, though warned, I was completely unprepared with how winter-like it was. I had to break out the winter coats to brave 10-foot visibility fog. But it was also nice to be in the city without the busyness of school. I realized that despite living a year here, there were some tourist things I'd neglected so when friends visited, we made our rounds to the Cliff House, Ferry Building, and Metreon. Also, things felt really different going to campus without seeing my classmates; I got very used to the high-school effect of seeing everyone everyday during the school year. But now, the weather portends an Indian summer, and it's quite beautiful most days. I guess this is why first year starts now. Now through October we should get pretty warm and sunny weather.

Case of the Day

I really liked the Case of the Day during our neuroscience block. The active learning aspect of it particularly appealed to me; although inefficient, if you spend a good amount of time investigating a clinical finding, radiologic image, or disease, it gets somewhat ingrained in your memory. The process of differential diagnosis is pretty fun too. Anyway, my newest project can be found here:

http://caseoftheday.blogspot.com/

It is updated every Monday, Wednesday, and Friday with a new case and the previous case's solution; it is loosely correlated with our curriculum, but will also have review for the boards.

Shark Embryo

This is a picture of a shark embryo from the Long Beach Aquarium in Orange County. They somehow opened up the egg so that you can see the shark developing inside. It's really cool; the egg will hatch into a viable shark January 2008. You can actually watch its heart beating and stuff.

Labwork II

I enjoyed working in the lab because of the latitude of freedom afforded to me; I could design the experiments I felt were most important, plan out my week in advance, and control the flow of activities. I really like the intellectual scientific part of it: determining what controls I should run, interpreting data, correlating findings with expectations. Much of my learning came from the troubleshooting and meticulous review of my experiments. Though frustrating, it is very rewarding to apply knowledge about theory to a very specific experiment gone awry.

The people in lab were fantastic. We had a lot of celebrations this summer, and one of the medical students who was taking a year off to do a Howard Hughes is an incredible cake designer. Having older medical students working in the lab was lots of fun; we had a lot in common to talk about and I could hear about all the scary things awaiting us in third year. It was interesting working in a large high-powered lab; though we saw our PI not unfrequently, most of the day-to-day was run by another PhD. I feel like I got a lot out of it, though I did not produce much. It was fun. I was funded by the Foundation for Anesthesia Research and Education (FAER) through a Medical Student Anesthesia Research Fellowship.

Labwork I

This past summer, I worked in the lab of Dr. Wiener-Kronish in the Department of Anesthesia. Her particular interest is in Pseudomonas aeruginosa, a gram-negative opportunistic bacterium that infects immunocompromised, cystic fibrosis, and burn patients. It's also a very important nosocomial (hospital-acquired) bug. My specific project was to create genetic constructs in Pseudomonas to investigate reciprocally regulated genes. I wanted more training in basic molecular biology techniques such as restriction enzymes, plasmid transformation, and cell culture. In particular, I cloned a few genes, attempting to engineer specific plasmids. It was unfortunately frustrating in that the project was not well prepared for me and so I had to work through a lot of problems that I didn't anticipate. I wasn't able to get significant results, so I'm still working on the project despite the difficulty of continuing research into the school year.

Stanford Stethoscopes

On Wednesday, I attended Stanford's Stethoscope Ceremony to celebrate a few of my friends who are beginning medical school there. It was really fun; I was quite glad I managed to snag an invitation. They had a reception at the posh Schwab residential center and quite a nice dinner (in fact, through my undergraduate years, I had never seen the inside of Schwab). The ceremony itself was less formal but more cozy than mine last year; instead of having all the students together for a formal presentation, everyone was with their families enjoying dinner while the speeches were delivered. The speeches were quite good, emphasizing the changes that need to be made to health care delivery. Instead of white coats, Stanford presents students with stethoscopes. This is a very Stanford thing to do; since the white coat separates the physician from the patient, Stanford instead chooses to give incoming students a stethoscope, which connects the physician and the patient. Though I have to say, I rather liked putting on my white coat for the first time during my ceremony. It was an excellent evening. Congratulations to my friends and the rest of the incoming class of 2007 at Stanford.