Playing Doctor

Anticipating the start of clinical rotations, we were oriented to hospital procedures and scrubbing techniques this week. They made for long days...thankfully there won't be a test.

Sterile Technique

Despite having classes behind us and the board exams ahead of us, we couldn't quite crack the books until we were oriented properly for our rotations. This particular exercise gave us an opportunity to "scrub in" from fingernails to elbows and donning a sterile gown and gloves. It can be a challenge the first few times trying not to contaminate oneself, but the no-pressure environment was perfect for learning this skill. We may not be as proficient as some, but at least we know the basics of the surgical scrub.

It is hard to believe that the second year of medical school has passed so quickly. By keeping us busy all the time and always preparing for the next exam or quiz, we didn't have much time to really slow down. Fortunately, all the grades have been posted and I am still in "good standing" with the university. It's just a matter of time before I can say the same about board exams. In the meantime, the morale boost we get from doing doctorly things will have to feed our fires for this career we have been working hard to achieve.

Board Prep Question of the Week

An 8-year-old boy presents to your clinic with a history of nonproductive cough and recurrent opportunistic infections. His mother claims that the symptoms first arose about 2 years ago and previous physicians suspected an immune deficiency disorder. A chest X-ray reveals patchy infiltrates and diffuse clouding. Bronchiolar lavage identifies numerous neutrophils arranged in isolated conglomerates. Nitroblue tetrazolium dye reduction test is negative. Which enzyme is most likely deficient in this child?

A. Alpha-ketoglutarate dehydrogenase
B. Dihydrofolate Reductase
C. Glutathione Reductase
D. NADPH Oxidase
E. Topoisomerase

Answer & Explanation

Easing the Pain

Like something seemingly out of a torture camp the Transcutaneous Electrical Nerve Stimulation (TENS) unit is actually designed to relieve pain and discomfort through a small portable device. 

A New State of Comfort

Finally able to breath again and catch up on my sleep, I still find my back and neck sore from the long hours of hunching while studying for exams. A good night's rest and a session of yoga at the gym quickly helped ease some of the tension that built up over the last couple weeks. For some people, however, pain can be an ongoing problem that limits their daily functioning and even compromises optimal health. Recently, I heard about muscle stimulators and their non-invasive approach to easing sensory and motor deficits. Despite their evil look, some people swear by their effectiveness as adjunct to common medicine.

Although not effective in all cases of chronic pain, TENS Units are an alternative approach to the use of medications and more invasive methods of treatment that aim to reduce neuropathic pain. By stimulating nerves to release inhibitory (GABA) signals, the sensation of pain can be reduced. Among the research is a case that shows there may be some benefit to the use of such systems in restoring sensation where it has previously been diminished. For additional information about LGMedSupply's products visit their online customer blog. Otherwise, if you have used a similar device, I would be interested in hearing your feedback on the subject.

Board Prep Question of the Week

An 18-year-old girl from Southeast Asia presents with symmetric ascending weakness below her knees. She has been unable to walk for 3 days. Physical exam reveals mild hypotension and papilledema. Upon respiratory support and administration of IV immune globulins and plasmapheresis, her condition resolves after 2 weeks. Which of the following is the most likely etiologic agent of her condition?

A. Acid sphingomyelinase deficiency
B. Arylsulfatase A deficiency
C. Infection with C. jejuni
D. Infection with JC virus
E. Microsatellite instability on chromosome 4

Answer & Explanation

Second Exam Week Six

Now that our classroom career is over and the last set of exams are here, it is time to study. Fortunately for us, the first tests last week were in Osteopathic Manipulative Medicine. This meant one good corporal realignment before a week of uncomfortable postures and mental torture.

Final Adjustments

"...Take a deep breath." I then waited as my study partner dropped his weight on my upper body and we both felt the audible release of a vertebral segment that was misaligned. In no time the pain was gone and we moved on to continue our studies. As this was our last set of exams, we had the task of performing a full body evaluation and applying a specific treatment of our choice aimed to restore function. Since we were successful in treating each other in practice, our partners the next day had little to correct during the test. I think I am going to miss these little "corrective" sessions.

The thought of being finished with school is really exciting. It doesn't take long, however, to remind myself that as soon as this week is over, it will be time to dig deeper in preparation for board exams. (So much for having a vacation between school and rotations.) One thing is for sure, this experience has been so much better than I could have ever imagined. Sure, it has been difficult, but it continues to pique my interest and lift my thoughts to a better future.

Board Prep Question of the Week

A 13-year-old figure skater botches a quadruple lutz and falls on her right outstretched hand. Several weeks later a cast is removed for a healed scaphoid fracture. She begins having episodes of intense burning pain, sweating, swelling, and redness that begin in her right hand and moves up her forearm, sometimes up to her shoulder. These episodes often occur when she is angry or upset. On exam her arm shows no visible abnormalities. Which of the following nerve types are involved in the pathogenesis of her disorder?

A. General somatic afferent
B. General somatic efferent
C. General visceral afferent
D. Special somatic afferent
E. Special visceral afferent

Answer & Explanation

Fetal Development

I remain in awe that a body can reproduce its genetic code and create life as seen in this video.

The Making of Mothers

Preheat the oven to 98.6 degrees, place it in the endometrial wall and let it slowly rise over the next nine months. If only fetal development were that simple. Below are some of the highlights of embryologic formation with which most people never really become acquainted. Welcome to life as a medical student.

First Trimester - Weeks 1-14

• Week 1: Fertilization, morula, blastocyst(Day 5), endometrial implantation(6) and hCG from the syncytiotrophoblast
• Week 2: A bilaminar disc forms(8) and uteroplacental circulation starts(13)
• Week 3: The primitive streak is evident and the central nervous system begins via the notochord and neural plate; appearance of somites(20)
• Week 4: The neural tube closes leaving cranial and caudal neuropores(23), limb buds develop(28), and the heart begins to beat
• Week 5: Facial development, pharyngeal arches and clefts take shape
• Week 6: Fingers start to appear(38), endodermal derivative development (lung, stomach, pancreas, intestines, liver, gallbladder, urinary bladder)
• Week 7: Toes develop, maxillary and medial nasal swellings fuse to form upper lip
• Week 8: Fetus has the appearance of a baby and begins to move; heart sounds can be heard
• Week 9: Eyes and ears form as face and other organs continue development
• Week 10: Male and female genitalia are identifiable
• Weeks 11-14: Fine hair (lanugo) starts to appear; muscle and bones develop

Second Trimester - Weeks 15-27
The bones begin to harden, finger and toe nails form while the fetal organs continue to develop. Movement can be felt during this period as the fetus kicks, rolls, sucks its thumb and learns to swallow.

Third Trimester - Weeks 28-40
The fetus will double or triple in weight from now until birth. The skin thickens with a layer of fat to maintain body temperature. The senses of hearing, vision, touch and taste are developed and used. Repositioning in the womb is not uncommon in preparation for delivery.

Birth
All I can say is that without it, I wouldn't be here. Thanks Mom, Happy Mother's Day.

Board Prep Question of the Week

A male infant has a cleft lip on one side that does not involve the alveolar process or the hard palate. A unilateral cleft lip results from the failure of which two facial prominences to merge?

A. Lateral nasal and maxillary
B. Left and right medial nasal
C. Maxillary and mandibular
D. Medial nasal and maxillary
E. Lateral nasal and Medial nasal 

Answer & Explanation

Medical School Family

Time management is definitely an issue in medical school. Finding a balance between the books, upcoming tests and family has been more of a challenge as time goes on. Last week, one reader asked how it all comes together on the family front. Rather than imply that I know exactly how it is, I asked my wonderful wife to share her thoughts.

Life as a Medical Student['s Wife]

Without blinking an eye I'll say it's tough.  Worth it?  Of course.  Before this experience, I remember talking to a friend whose husband had just finished dental school.  She said, "I proudly wear my wife's badge for having gone through that experience."  I laughed in ignorance.  Now familiar with the battles waged through this medical school experience, I fully support her honorary wife's badge.  While Josh and I have chosen not to have children in school, (heaven help those courageous couples who do have kids) there are plenty of battles we endure.  The two struggles that seem most prominent for me this year are time/patience and emotional connection.

Last year I wrote about adjusting to the first year. This year has been most trying on my patience and I've felt like my life has had to take a backseat to his career. I've been offered many opportunities to advance in my career which I've had to turn down due to his current position and our location. I've been supporting Josh from day one of our marriage. I take that back...after our amazing honeymoon in Paris and Eastern France, I've been the sole provider. This year we will celebrate our fourth anniversary. During these four years I've worked full time as a graphic designer, part time as a yoga instructor, freelance designer, painter, letterpress designer/printer, photographer and figure skater- simultaneously. Even with all of that, Josh manages to stay busier than I and buried in books for longer hours than I work. That means when there is down time I also feel obligated to take care of everyday chores. Usually, this is what Josh and I fight about - the chores - when we're both exhausted. I think we once argued for 30 minutes about our pantry door being closed vs open until we realized the absurdity of the situation. 

This year I've felt more distance between us also.  Because of our clashing time schedules, it's difficult to connect. Last year I embraced every moment of time he had available and dropped whatever I was doing to have some time with him. My responsibilities this year are more demanding and I can't always do that. That also may have been a bad habit I enabled Josh to expect. It is difficult to feel emotionally detached due to our schedules, but even more demanding to feel compelled to switch the emotions on whenever it's convenient. In the question posted last week on the blog, the fear of affairs during long hours of study after school was addressed. Josh's study partners are two Mormon boys, so it hasn't been a direct fear I've had to face, but it would be if he were studying with the opposite sex. We've learned to put each other on our daily lists of things to do. It's important to make some sort of connection in whatever time you share, to keep the pilot light on. We recently watched a NOVA documentary called "Doctors' Diaries" that followed the lives of seven medical students through medical school. It addressed the reality of divorce, the difficulty of relationships through school and the experienced perspective of the doctors after school. I would recommend watching their stories and being honest and real about what your unique relationship requires to stay healthy.

Thank you for your thoughts Willow. I agree that this has been a trying process with moments of joy. One of the most important things I learned before coming to school was from a doctor friend. He said that as a student we can set our own schedule and if we want our family to be a priority then choose it to be such. It is crucial to work with groups, patients and other classmates, but most importantly to know that our families are standing behind us. If it were not for my wife, I would not be where I am today. Thank you for your support and encouragement, you certainly deserve a part of my degree.


Board Prep Question of the Week

You went to visit your friend from college who recently had a baby. She named him Johnny. As the mother was gently letting you hold Johnny, he appeared really anxious and started crying once you reached to hold him. Johnny's age is most likely to be:

A. 2 months
B. 3 months
C. 5 months
D. 7 months
E. 4 years

Answer & Explanation