Peanut Butter and Jelly

The gourmet classic of any medical student is obvious; one slice of bread slathered in fruity preserves married to another slice plastered with smashed peanuts. It’s the “go-to” of meals when the cereal box has poured its last bits or the milk carton has gone dry.

The (Un-Starving) Nourished Student

Available on my shelf of kitchen space I have a small variety of cold cereals, half a loaf of bread, half a container of peanut butter and a can of beans. The half shelf in the refrigerator is barely enough room for a half gallon of milk, a handful of bananas, celery and a few remaining hot dogs. The granola bars are used to stock my work bag in case of a snack attack and I have some Tootsie Rolls to complement my meals as a small dessert. There is no question that my in-house meals are lack-luster and definitively not the most nutritious. The occasional meal is had at the hospital or a fast food joint on the way there which is surely not helping my case. I am just now realizing that I don’t even have said jelly on hand…how pathetic is that?!

Just when you thought medicine was about teaching healthy habits, you notice that those who teach it are having a hard time following the rules. Certainly, this does not go for every student as the outliers exist, but if you ask, there is commonly a stock of supplies to make the most basic of meals. Whether short on time to prepare meals, no desire to eat healthier, or an attempt at saving money we are probably not properly filling our fuel reserves. One student I work with is staying in a local hostile making the effort to find the nearest free meal even if it means walking into a nearby hotel for their continental breakfast! The best counsel I heard a while back: “somewhere there is a free lunch, and it is my job to find it.” It holds true, but when the advice proves futile I return to my meals of simplicity with minimal ingredients and little variety. So Mom, no need to worry, I am being fed and there is something from every food group.

Question of the Week

A known alcoholic man presents to the emergency department showing signs of confusion, unsteady gait and horizontal nystagmus. Upon questioning he tells you he does not remember much about the day but just finished eating a meal fit for a king. What is the first step in treatment and what structures are likely being affected?

A. IV glucose, mamillary bodies
B. IV thiamine, hippocampus
C. Oral glucose, hippocampus
D. IV thiamine, mamillary bodies
E. Disulfiram, amygdala

Answer & Explanation

High Speed Medicine

As a kid, one of the best parts of the parade was the emergency vehicles blaring their horns and flashing their wild strobes. Sometimes though, lights and sirens just never get old. Since I am currently rotating in emergency medicine, it seemed fitting that I would get my share of prehospital care on the city streets.

Prehospital Medicine

The high pitched tones squealed over the radios and we were all out the door in a matter of seconds. With the lights flashing in a wild furry and the siren blaring, we flew down the city streets on our way to the injured and ill. For any who have never gone "Code 3" in a vehicle, it is like the best commute ever; no red lights, stop signs or question of who has the right of way. We were parting the sea of vehicles all the way to our destination. The little information dispatch provided was all we had to prepare for the call. Once on scene, we could size up the patient and events that had transpired only minutes earlier. The few things we carried were usually sufficient to get our patients from home to hospital.

Countless times in the hospital, I have heard the Emergency Medical Services (EMS) get a bad wrap. Perhaps we are all jealous they get to ride around city streets at high speeds and make loud noises in the process with all those attractive lights. In reality, I think there is a disconnect between the providers in the field and those in the hospital. We are on the same team looking out for the patients that so desperately need our help, but unfortunately forget that all too often. I feel bad when doctors don't take the time to listen to EMS. They have spent the first moments of patient interaction building a relationship that will ultimately be transferred to the hospital personnel. Without their efforts, it would be a disaster getting people to the hospitals. In a sense EMS is bringing medicine to the people.

Although my time with EMS was limited and not required of me, I had a blast being among men and women who save lives on the run. I was welcomed into their department/home and to dine at their dinner table. They let me get my hands dirty and shared how they wished more would learn what they do. If you ever get the chance, I would highly recommend spending a day on the crew, they have plenty to teach. To those at San Bernardino County Fire Station 71, thank you.

Question of the Week

A 56 year old homeless male is brought in by ambulance to the emergency department after being found on the ground with what appeared to be hematemesis. He is now alert with mild confusion. His blood pressure is 86/48, heart rate 124 bpm and respirations 28 bpm. He is afebrile and weak. It is initially thought that he has a gastrointestinal bleed. What is the first step in management of this patient?

A. Normal saline to replace lost fluids
B. IV Octreotide to slow bleeding
C. Ensure a patent airway
D. Blood transfusion to replace lost blood
E. Guaiac testing of vomitus

Answer & Explanation

Life as a Patient

Finally nearing the end of my hospital stay, I have gleaned a great deal of information and experienced my share of ups and downs. Surgery was a difficult experience as it left me with pain, wounds, and the after effects of anesthesia. Being in the ICU with all of its high-tech glory was much less fun than I remembered from rounds.


Post-Operative Recovery

Fortunately, I was able to avoid catheterization. Nonetheless, the anesthetics had a long lasting effect that disturbed both my gastrointestinal and urinary tracts. Every time I tried to drink fluids, my stomach would have nothing to do with it. I had to keep the emesis container within reach as there was no way of judging how my body would react. It was more annoying than anything as the cottonmouth was rather unpleasant. Between medicated naps and side aches from my freshly placed chest tube, all I could do was wait for the anesthesia to wear off with my barf bag in hand. Learning to adjust to my new wounds and pains was going to take some time, and all I could do was wait. As the clock rolled, I became hungrier and dared to try solids. It tasted good, went down well and sat well...but only for 10 minutes. It was then that I wished I had an emesis bag the most; a simple device I could put on and forget about. Luckily, it became easier to hold the food in and now I had to get my bladder to cooperate. With some serious concentration, faucets running and a friendly coaxing from my visitors, the bladder situation was overcome in due time.


Little did I know that the next few days would be worse. Inflammation, muscle aches, tubes, wires, medications and the list goes on. Now I was starting to understand what my post-operative patients had been experiencing. From one unpleasant experience to the next, I was now on the doctor's schedule awaiting instructions and decisions. My job was to report any problems, stay attached to all my wall connections, exercise my lungs and generally get better. I was happy to hear I was the most stable patient on the ward, which was to be expected as I was also the youngest. The TV was boring, my neighbor's moans annoying and the food not always appetizing. Getting up and walking around the unit was the most enjoyable activity I participated in during my stint. Something we so easily take for granted had now become the highlight of my day. At last discharge is in sight and I can soon recover in the comfort of my own home. This experience, however, has made a significant impact on my perception of health care and the way I intend to approach my future patients. What a great way to spend my vacation month.

Question of the Week

As a new patient on the surgery ward you are asked by the dietitian make your next meal order. Which of the following will have the worst effect on your health and recovery?

A. Turkey roast with mashed potatoes and broccoli
B. Chicken fingers and French fries
C. Meatloaf with mixed vegetables and a dinner roll
D. Shrimp pasta alfredo with garlic bread
E. Chicken salad wrap with clam chowder soup


Answer & Explanation

Holiday Festivities

(Click image to view Doctor Fizzy's medical cartoons)

Just in time for the holidays is the spread only a physician could love. Textbook descriptions of anatomical abnormalities may not be a popular thing to talk about, but somehow they always seem to make it to the dinner table. For an explanation of these rare delicacies consult your local medical student or physician.

Holiday Cheer

Medical students usually dream of this special time when they get extra time to sleep in, experience a comatose state in front of the television, or just simply not think much at all. That is of course if you are in your first two years of medical school. The clinical years are not as relaxing; resembling something closer to a paid profession. We work all the way up to the holidays and sometimes on those special days just chugging along trying to keep pace. It continues to be rewarding, but does it really help in the long run to have one extra day of clinic...really? The break would probably be better for us mentally than stressing about a few hours of scutwork.

The cartoon depicts the feast well and I could imagine a dessert platter offering the following: cafe-au-lait spots, peau d'orange, cherry hemangiomas, or berry aneurysms. As long as you don't have any of these questionable entities yourself, your holidays are already off to a good start. So whatever your plans this holiday season, elaborate or simple, I hope you take some time to enjoy the finer things in your life - even if you have to work on a supposed day off. I hope you all enjoy the beauty of the season and stay in good health. Bon appetit!

Question of the Week

A patient is admitted to the hospital with shortness of breath and found to have a pleural effusion on chest X-ray. Thoracentesis is performed and the fluid is sent for laboratory testing. Results of the fluid analysis are: pleural protein 8.0, serum protein 6.5, pleural LDH 500, serum LDH 100. Based on these findings, which of the following is the most likely etiology of the pleural effusion?

A. Bacterial
B. Congestive heart failure (CHF)
C. Cirrhosis
D. Nephrotic syndrome
E. Pulmonary embolism

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

Industrial Health

Among the books, papers, and anatomical models in my office I have a small collection of medical art hanging. In the bottom left corner is an industrialized piece by Fritz Kahn that depicts the body as a machine. "Der Mensch als Industriepalast" has recently been given new life in this video animation, "Man as Industrial Palace."



Body Systems

Our newest adventures follow the gastrointestinal tract from top to bottom. Like the chocolate morsel in the animation we are developing an understanding of the chemical breakdown of foods in healthy and diseased individuals. At first, I thought there was no hope of grasping the workings of the liver and this complex array of tubes (If only it were as simple as the animation). Despite its complexity, there are occasional "aha moments" when the on-turning light above my head illuminates a concept I've known before, but never truly understood. Compared to days of confusion, those are usually what constitutes a good day.

We have not yet finished our systematic approach to the body. Looking back at my second year of medical school, however, I feel there has been a significant amount of progress. We are constantly developing a new vocabulary and a working knowledge that were non-existent only months prior. This process definitely has a steep learning curve and it is no wonder that doctors are considered to be among the top 1% of the world's most educated professionals. A daunting reality that is appropriate, considering we are expected to care for the life of another individual.

Board Prep Question of the Week

A 46-year-old female with a history of painful spasms of the fingers in the cold complains of 2 weeks of fatigue, pruritus, and abdominal pain. Her exam is notable for scleral icterus, right upper quadrant pain, and a liver span of 11cm. Her laboratory values are as follows:
AST: 110
ALT: 102
Alkaline Phosphatase: 256
Total Bilirubin: 2.8
Direct Bilirubin: 1.9

An abdominal ultrasound shows no obstruction. A liver biopsy is taken and shows destruction of small interlobar bile ducts. What antibody test will likely be positive?

A. Anti-Scl 70
B. Anti-ds DNA
C. Anti-mitochondrial
D. Anti-smooth muscle
E. P-ANCA

Answer & Explanation

Giving Thanks

In this season of thanksgiving, I reflect on that for which I am grateful. My supportive family and friends are at the top of my list along with endless opportunities to serve my community. I am usually not grateful for the ability to grow so much hair on my lip, but this month is a little different.

Local Volunteer Opportunities

With the little time we have outside of classes, it is refreshing to give back to the community on occasion. Since we are in medical school, it commonly comes in the form of optimizing health through sports physicals or public screenings. Recently, I joined my peers in a 5k walk for chronic hypoinsulinemia on behalf of the Juvenile Diabetes Research Foundation (JDRF). In addition to raising money for a good cause, we caught a little fresh air and exercise at the same time.

In an ongoing effort to address prostate cancer awareness, men all over the world are "changing the face of men's health" by growing a mustache for Movember. I joined my classmates as Student Physicians for Fuzzy Philtrums, with the goal of contributing our follicular skills to this beneficial cause. If you have a prostate or love someone who does, please contribute to this noteworthy cause by sponsoring my fuzzy philtrum with a small donation. All proceeds go to the Prostate Research Foundation in cooperation with the Lance Armstrong Foundation. (After clicking the above link, you will be able to provide your contribution information online, if you have questions, please leave a comment.) Your generosity is greatly appreciated.

Board Prep Question of the Week

A 29 year old female with type 1 diabetes goes on a trip to the Caribbean and loses her insulin on the way. Three days after her last insulin dose she goes to the hospital. Lab work shows hyperglycemia and increased anion gap metabolic acidosis. Which of the following pathways is mainly responsible for providing the substrate of her acid-base disorder?

A. B-oxidation of fatty acids
B. Catabolism of branched chain amino acids
C. Citric acid cycle
D. Gluconeogenesis
E. Glycogenolysis

Answer & Explanation

Organization Learning

Once again the Jewish holidays Yom Kippur and Sukkot have come around offering a respite in our studies. The extra time off has made life a little more bearable.

Time Management Strategy

When the school year started, I had no idea how much more difficult this year would be in relation to first year. I spend a great deal of my time at school late into the night preparing for exams, quizzes or simply studying recent material. The environment provided there helps to maintain focus, where the home environment can easily become distracted...especially if the refrigerator has been recently stocked.

I have found that spending a little time organizing oneself for a few minutes makes a significant difference when it comes to accomplishing the necessary tasks. It may be a simple check list or a detailed breakdown of how each hour is going to be spent. In any case, time management is critical to our success as medical students. Unfortunately, we sometimes forget to plan in the important things such as family, sleep and exercise. They all have their place and need to be considered into the equation. Thus when the days off come around, there is much rejoicing.

It is important to find what works for you. I break down my material into subject matter and then what I feel can be accomplished with the time I have. Commonly, it is by deadline prioritization - if the due date is coming, it gets top priority. Occasionally, I will complete a task simply because it can be done quickly, thus leaving one less thing on my list to worry about. Whether you make a spreadsheet with all your tasks, create an online task list that can be accessed anywhere or just write it down on an index card, being organized from the start will maximize your time and lower your stress.

Board Prep Question of the Week

An otherwise healthy 10-year-old boy develops blotchy areas of erythema that are pruritic over the skin of his arms, legs, and trunk within an hour every time he eats seafood, followed by diarrhea. These problems abate within a few hours, and physical examination reveals no abnormal findings. Which of the following immunologic abnormalities is he most likely to have?

A. Cell mediated hypersensitivity.
B. Hypergammaglobulinemia
C. Immune complex deposition
D. Localized anaphylaxis
E. Release of complements

Answer & Explanation

Shadowing

Now that school is out for the summer, we have taken to the clinics to see the local professionals in action. Job shadowing with a doctor permits medical students to learn by observation.

Job Shadowing

As I stood in the exam room, listening to the physician taking a history and performing a physical, I was impressed at how much I had learned from my first year of medical school. The terminology was not completely foreign and the medical principles behind diseases were still in my retrievable memory.

TUN students are responsible for shadowing two physicians for a period of 24 hours each. In an effort to cut down on wasted rotations, I chose to observe a gastroenterologist and an anesthesiologist. Despite some interest in their professions, I do not currently expect to choose either specialty, yet I continue to have an open mind towards both.

Thus far the experience has taken me to both clinic and operating room where I observe the doctor's responsibilities and techniques. Occasionally, the physician would surprise me with questions (known in medicine as "pimping") which often catch me off guard. If I can pull the answer out in a split second I feel pretty good, if not, they usually answer the question for me. That said, I find myself studying at home in between visits to prepare for my next pimping session.

Clinical Corner

Shadowing

My clinical preceptors have been fantastic, offering opportunities to educate and learn, they offer more to learn about their fields of practice than a book possibly could. To gain the most out of this experience, I would have appreciated a little more advice from our faculty. For what it is worth, I am listing some job shadowing tips. As usual if you have additional thoughts, please share.

• Set Appointments Early - Contact your preceptor early to set up shadow experiences (especially if it is a class assignment), there is greater flexibility and secretaries have little empathy for those who wait until the last minute
  
• Dress Professionally - This is a "no-brainer" but unfortunately there are some who do not
• Arrive Early - Plan to show up at least 15-30 minutes early, in the event a preceptor starts early or has time to talk it will be to your advantage
• Research the Position - Know a little about what your preceptor does and the educational ladder to get there before shadowing
  
• Questions - Do not overburden the preceptor with questions and carry a card to write on when they are busy performing their responsibilities so you can ask questions at more opportune times...nevertheless, ASK QUESTIONS, you are there to learn
• Shadow - Unless they ask you not to follow or copy them (hand washing etc.) you are there to experience it, do it too
  
• Study - If you have multiple days to follow a preceptor, take the time at home to study relevant terms, cases, diseases or ideas that you observed in preparation for the next visit
• Be respectful - Be nice to the other staff in the office and the patients or clients you work with, you never know when you will see them again
• Show Gratitude - Everyone deserves your appreciation for the opportunity, share it verbally and send a simple note of gratitude once you have completed your experience
  

A Welcome Vacation

This is essentially what I have looked like for the past five months. If my nose wasn't in a book looking for the answer, it was likely that I was in lecture or group study.


First Semester

The semester has come to an end and the final grades are not yet posted. Exams were an extremely nerve racking experience to have spent so much time preparing only to find I was partially being tested on the material I didn't review in detail. Fortunately, I had plenty of house to clean and other projects to occupy my time while I mulled over my responses. After a weekend of making furniture, I think I am prepared to see my grades for better or worse.

Overall this first semester started as an exhilarating experience. When the novelty of it all wore off and each day blurred into the next, the reality of medical school sunk in deep. Hard work, all the time. Coming into this I knew it would be the case, but the three classmates who dropped out didn't know what was coming. Medical school is difficult and rewarding at the same time. I am still very excited to be learning the art of medicine and have a much greater respect for the practicing physicians who have endured through a similar experience.

Living in Las Vegas I didn't expect to have a 'White Christmas', but we were all surprised when 3-8 inches of snow fell on our city. As the last time this happened was 30 years ago, everyone was in shock. The worst part yet is that schools were closed for a day including Touro, despite the final exams. As if that didn't add to our stress. Coming from a rich background in snowfalls much greater than 3 inches, I had a hard time swallowing a 'snow day'. Oh well, now to enjoy my two weeks of vacation before heading back to the grind.

Clinical Corner

Dietary Fiber

With oversized holiday meals, excessive treats and plenty of unhealthy goodies to temp us, I thought a healthy alternative would be good to discuss. Foods rich in fiber have many health benefits that we can not afford to neglect for now and our future.

Better than the sprinkle on fiber supplements are the foods with natural fiber (grains, fruits, vegetables etc). Benefits include:

• Relieving and avoiding constipation - Fiber absorbs water making it easier to pass food without straining the bowel.
• Prevent diseases - Cancer, heart disease, diabetes, diverticular diseases, and kidney/gallstones
• Weight control - In addition to giving the feeling of satiety, fiber will bind to bile made in the gallbladder. Bile is used to break down fats in the diet. Normally, very little bile is lost, but when bound to fiber it is removed from the body in greater quantities and the body loses bound cholesterol more readily.

Have a great holiday and remember to eat healthy. Other great reading and recipes.