Just running the bridges

They say it's a marathon and not a sprint, and I partly agree; we all spend time just running up and down those bridges. Sometimes it's a nice, even jog, and other times it is, in fact, a mad sprint. The finish line isn't a line perse, but a solidification of the bridge, such that crossing it is second nature. Maybe the bridges also get shorter; the longer I run them, the less time it takes. The bridges scattered everywhere throughout this mental landscape - some of them are parallel and have nothing to do with each other, and some of them are in series, connecting a winding pathway of clusters of information, ripe for an academic pilgrimmage.

Rome wasn't built in a day, and one can't run all the bridges in a day either - part of making sure they're all strong enough come test day is balancing them out. You can't spend all your time running the bridges that provide the prettiest scenery - you've got to cover them all, otherwise, the ones you've neglected will fall through and, come that inexorable, imminent day of reckoning, you won't reach one cluster from another. They don't last forever; if you don't run them, they'll fade from existence. At the very worst, though, they'll just crumble to the bottom of the mental chasm. At least you'll be able to rebuild. So I spread them out and jog them all. Yesterday, I ran a circuit of the bridges between parasites, those connecting the clusters of antiparasitic and antifungal drugs, the bridges spanning the chasms between hypersensitivity, and those connecting bacterial genetics. I also revisted some bridges I'd built for the first test - those connecting autacoids (headache medication, serotonin blockers, etc), and those spanning NSAIDS ( basic, non-opiate pain meds). I hadn't been throug those bridges in a while, and they'd faded more than I'm comfortable with - they weren't entirely gone, but I'll have to run them a few more times and make sure they're sturdy.

You know what's funny? Pathologists have the most interesting sense of humor. First, they always liken things to food - nutmeg liver, cheesy tuberculous necrosis, cafe-au-lait spots, banana-shaped ventricles, etc. Also, they like to take beautiful sounding words, and describe something absolutely wretched. If I hear necrotizing fasciitis, I know it's bad. But if I hear Anasarca, I think of an attractive woman - not edema all over your body. What about Melena? Lovely sounding name, right? Not bloody stools. Those pathologists must have had very strange romantic lives...

Cluster Bridges

If ever you wonder what it is I do all day - I build bridges. Some are as simple as a plywood plank across a backyard stream, while the importance of others rivals the size and scale of the Brooklyn Bridge - I build bridges all day, and then I walk them - back and forth, and back and forth.

I've realized that that's pretty much all they want us to do - walk down the cluster bridge. When I say that, I'm referring to the learning style here. There's a definite right answer and all the other answers are almost definitely wrong - that being the case, there's usually only one path: the Cluster Bridge. The clusters I refer to are groups of information, which, for my purposes, are given to me in the stems of questions. It is my task, then, to travel down a cluster bridge and arrive at the complementary cluster - the right answer. I call them clusters because they are always groups of pieces of information. If, for example, the cluster I'm given consists of a two-year old with mental retardation, aggressive behavior and hyperuricemia who bites himself - the cluster I respond with consists of Lesch-Nyhan Syndrome, HGPRT deficiency, and X-linked recessive inheritance. Those two clusters are, in my mind, linked by a firm bridge, so well-traveled, that by the time I read the bit about self-biting, I'm already way across the mental chasm, already at the end of the bridge.

Of course, we're being taught to be compassionate, and to relate to patients as people who have placed their trust in us. Right now, though - as I study for the exams which will determine my career, of course thinking of patients will help - but what I'm really trying to do is solidify the ephemeral mental bridges between oftentimes disparate pieces of information. Every time I walk across, the bridges become just a little firmer; repetition and explanation make those cobblestones easier to see. When I'm starting out - just learning something - I have no idea why the hell one bridge links two things. Chloroquine treats malaria? Sure - I'll buy it. I have faith that there's a bridge there. If that's all I had to go on, though, I might just forget where the bridge is - it's hard to see. Wait...what's that? Chloroquine makes it impossible for plasmodium vivax, a malarial parasite, to convert the heme it eats from red blood cells into hemozoin? And regular heme is toxic to the parasites? I may not know exactly why hemozoin isn't toxic, but I can see those cobblestones, and now I have a much firmer, much more comfortable cluster bridge. I'll walk over it again and again, maybe widening it here and there, adding to the supports, slipping in pillars and columns - I build bridges all day.

Exam day is a structural assessment.

The Rainstorm Cometh (cameth?)

There's been talk of hurricanes and rumors of hurricanes, but up until yesterday, all we saw was a little bit of rain. Granted, it was a rain that seemed to be timed with maddening precision - occuring exactly during the lunch hour, especially when the morning had been sunny, so I of course never brought an umbrella - but it was just rain. Yesterday was a different story.

After getting up for the weekly Case Presentation - a teleconference between the Ross campus and the Princess Margaret Hospital in Roseau, this week covering prenatal corticosteroid administration (to help little babies' lungs develop), Nicole and I returned to our normal classroom for a rousing series of lectures - some anxiety disorders, a little bit of human sexuality, some psychopharmacology, a little neoplasia, etc. However, 5 minutes shy of 10:00am, one of our professors came in with an urget announcement from the prime minister of Dominica: effective immediately, all businesses on the island were to shut down due to the approaching storm - everyone was to go home.

Great - day off, right? My first thought was for the student I tutored - their head and neck practical was today, and they'd lose the rest of the day to study. Next, I wondered when our already rigorous schedule would allow for making up the classes. Nicole and I filled up some water bottles, and then headed on back to PBH. And now, allow me to quote Genesis 7:10:

"And it came to pass after seven days, that the waters of the flood were upon the earth."

I've been in heavy rains before, but this was something else. We decided to wakl back along the street, because the little cow trail we normally walked to class every morning was sure to be a sloshing mud-hole by this point. So we're walking down the street, and I'm holding the umbrella (I remembered it!) darn-near horizontal, because the wind is coming so hard. This torrential downpour hit us all at once; 5 minutes before, the skies were merely a dusky gray, and I was thinking "they're shutting down the island for this?" So we're making our way down the road. I might as well have forgotten my umbrella, because within seconds, Nicole and I are absolutely soaked. We made it down past the study space, and then around the pool by Ross housing - to find a rushing, muddy river has materialized from the sidewalk between the pool and some buildings. By river, I mean more than ankle deep - but soon after, we were home free.

The storm is raging around us, and what do I do? Take pictures! The bucketfulls of rain had largely subsided by this point, even though it maintained a steady drizzle for hours. That being the case, I snuck out onto the top of the building (shh....that's between you and me).

Now I know that it may not look like much, but keep in mind that all of that swirling seafoam you see is normally as clear and smooth as glass. I made my way down from the top of the building to get right into the middle of the action - I snuck down into the seaside, open air restaurant close to where we live. Looking back, it probably wasn't the best idea because I was up to my ankles in muddy water and I couldn't see the crabs (or whatever other disgusting things had been evicted from their hovels in the dirt by the water), but I was out of there quick-quick.

Everywhere you see water is supposed to be luscious, neatly kept grass, and quaint stone walkway.

You can actually see how the raging storm has smashed our little dock into kindling - part of it washed away towards the Cabrits. Now I know that, in the grand scheme of floods, this wasn't so bad - first of all, the water has someplace to go; the sea is only 20 feet away. Also, it wasn't that much water, but it did all come at once. So, we just relaxed for the rest of the day. I finally finished Stephen King's Liseys's Story and Dave Eggers's You Shall Know Our Velocity. There was also quite a bit of reading done over neoplasias, and a little bit of reviewing fungi, yeasts, and bacteria. There was actually more reviewing than I would have liked - the cable was out.

Halfway through the day, I sent out a really long e-mail to my anatomy group. I hope they're doing alright - they're taking the practical exam right now.

In honor of the presidential election, Nicole and I have made the joke realized that, the first antibody to bind to a pathogen, IgM, actually means "immunoglobulin Maverick". However, that first response isn't enough, and if thats all you've got, your blood runs thick like syrup (it's called HyperIgM). What needs to happen is a process called "isotype switching". I guess you could say that our antibodies go through a change we need.

Just checking in

We've had deceptively little to do over the past few days - the week of a mini is always like that. I go from panicking about not cramming as much learning and reviewing as I can into every minute, that, as soon as the test is over, I catch myself going - "what do I do now?" Of course, there's relaxation to be done and sanity to be recaptured, but it's still a bit of a strange feeling. This past week, though, we truly didn't have much class - a bit of microbiology (most of which was review), some hardcore epidemiology, and a little bit of behavioral science. Oh yeah....I forgot about the pathology.

Here I have a tiny complaint - after spending 15 minutes telling us how qualified he was to teach, our professor for hemodynamic dysfunction then proceeded to make the subject boring. I'm sitting there thinking "How DARE you!" Look at it this way - no one cares what an E-cadherin is, or about the innervation of the stylopharyngeus muscle, or which pyrimidines are made. Everyone, though, knows someone who's had a heart-attack or stroke. How blood works and what happens when it doesn't (clotting, thrombi, emboli, shock, etc) strikes me as TERRIBLY important, and I'm a little offended that it wasn't done justice - this is something that, no matter what specialty I go into, will kill some of my patients. However, I can't really rail against the professor; I should be placing the blame on whoever built this schedule.

Though I've felt like there really hasn't been that much to do (even though I still haven't finished Stephen King's novel Lisey's Story), I'll tell you one group of folks who are running around like newly decapitated fast-food fowl right now - the second semester. You see, this Friday, they have their practical over head and neck. That means that I'm going to be pulling some extra TA shifts, just to make sure they've all got it down. It should be fun; I'm perhaps the only person I know who enjoys going into the lab.

Another test complete

On Monday, we had our first test of third semester - and I have to say, I was a little surprised. We have 5 credits worth of behavioral science this semester, and I figured that, with my major in psychology, I'd have a far easier time with this subject than anything else. For one thing, I didn't pay enough attention to epidemiology - I'm pretty sure I did alright, but if there was anything this exam reinforced, it was that Behavioral science is not just B.S. Also, there was blistering ambiguity on the part of those professors charged with constructing questions to test our knowledge of early childhood development. Granted, it's more of a soft science, but writing a decent question shouldn't be that difficult. So, strangely, by the end of the first twenty questions, I found myself craving some pharmacology or pathology. Both of those went very well, I think - I know I missed at least one pharm question, but only because I took it too literally. Pathology was nice to us - they were fair. Micro and immuno, however, though they were fair, obfuscated the questions unnecessarily, I thought. All told, I think it went well.

The night of the mini is always a big party night. I distinctly remember growing too old to party like a 20 year-old - I was at some frat party during my junior year of undergrad, and suddenly just felt very old, and very out of place. So, I didn't join in the revelry. I did, however, go to the Beach bash - a cookout/t-shirt giveaway/party on the beach - and am still wondering why, whenever t-shirts are ordered (1) they never fit and (2) they never order enough. That night, Nicole and I took some time off to relax and went to see a showing of Indiana Jones and the Kingdom of the Crystal Skull. Much of the filming was done at Yale, and I was pleasantly surprised to see streets I'd walked a hundred times, and I'm pretty sure they even showed several buildings I lived in. When all was said and done, though, it was bit far-fetched. Ark-robbing Nazi? I can deal with that. Finding the Holy Grail? Sure, why not. I kind of have to draw the line when it comes to aliens, though.

I thought I'd add this follow-up, on that double-arm transplant for the German farmer - he's doing well and is learning to use his new appendages. This is one of those things that's just absolutely fascinating.

Third Semseter and Memories of Buenos Aires

I've been negligent again. This time, though, it's with very good reason - this semester is simultaneously far more interesting, and far more difficult than anything I've done before. We've begun the classes that actually feel doctorly - gone are the banal prerequisites of biochemistry basic histology. In their place, I find myself faced with pharmacology - something I feel I'll use forever; pathology - the stuff I imagined when I envisioned medical school; microbiology and immunology - all the bugs that make us sick, and how we fight them off; and behavioral science - or the class I call how to act like a doctor. I'm loving it, needless to say - I find it far more interesting to immerse myself in the complexities of the different types of inflammation, with all of their signs and symptoms, causes and presentation; I find much more pleasure in constantly reviewing notes on indications and counterindications for the first of what I'm sure will be hundreds of drugs I'll have to commit to memory - than I found anything I've done thus far. Hopefully, I've been doing a good job studying - the first test is on Monday.

I've also made my way to something I've been looking forward to since I learned it was a possibility - I'm an anatomy TA. My sessions meet twice a week, and thankfully, I've got the second semester class (reviewing head and neck anatomy is much less painful than, say, the brachial plexus). Due to the rectification of some bad planning (through which I personally suffered), the current second semesters are now learning head and neck at the beginning, along with the various tracts and cranial nerves they're also memorizing for neuroscience. However, much to my chagrin, this class is far more careless and lazy in their dissections than my class was. Seriously - I'm not just over-fondly recalling my times spent inhalling formaldehyde while elbow-deep in cadaverous cavities - I received an e-mail today from the head TA attesting to the shoddy work. I'm encouraged to encourage them to do better and, moreover, if I want to go in and clean up some of their dissections, I'm more than welcome. I know you can't see my smile, but believe me - it's there.

Time is different now. There's simply less of it, and I don't think the trend will change any time soon. Technically, we're taking fewer credits, but this information just seems so much more important to me. Part of the reason for that is surely our ICM (introduction to clinical medicine) clinics, in which we're learning not only how to elicit a patient history and organize the information, but how to examine the patients. The physical exam, it seems, is traditional mainstay of medicine that, time and again proves its worth. While some things like the Water Hammer Pulse are more tradition than useful (no one uses it, but it'll still be on the test), most of it feels incredibly important, and, if what everyone says is true, is the most important tool physicians have in treating patients.

Memories of Buenos Aires

One of the things that Nicole really wanted to do when we first decided to make our way to Argentina was to go to a Tango show. After arriving, we decided to solicit the local opinions, and the gentlemen who sold Nicole and I our leather coats all agreed - the best tango show - bar none - was La Ventana. At the hotel front desk, I made reservations, and we decided to make this our big "anniversary dinner". Everything was taken care of for us - a rather obese gentleman in an old, threadbare sweater arrived promptly at 7:00 on Friday and bussed us, along with a few other hotel guests, to the best tango show in all of Argentina.

Much like everywhere else we visisted, the food and the wine were fantastic, and we enjoyed our dinner before the show ever began. Here's a picture of us taken by the gentleman sittin at the table next to us, with his young dauther, mother, and trophy girlfriend (who may or may not have gotten along with the daughter too well).

Now - I'd never seen tango before (TV doesn't count), and I must say I was quite impressed. Tango happens everywhere, it seemed - a little square on the pedestrian street in front of our hotel turned into a nightly stage for comedians and tango-dancers alike. However, La Ventana was the cream of the crop.

It wasn't just tango, though - it was a historical Argentinian culture lesson. We were treated to some traditional, native (I think) music, and even some Gaucho dancing, which led me to dub the gentleman below The Argentinian Ninja.

This guy was really, really good. Little wooden balls were tied to the ends of his strings, and he swung them around, beating on the floor with a rhythm and speed that made my jaw drop. Easily, this guy was my favorite performer of the night. It must have been a little difficult for him - for all of the other performances, the stage was full of dancers and singers (whom I'll get to in a bit), but this guy came out all alone, and started on a not-very-exciting dance. I felt bad for him, until he whipped out his props, and really got into his act (as is evident from the picture).

The singers were fantastic also - I'd have probably enjoyed it a bit more if I'd paid better attention in my high-school Spanish classes. Apparently, the owner of La Ventana sang in the show - here's a picture of him below. He worked the room, singing Por Una Cabeza, the famous Argentinian song about a love - and gambling on horeseraces. It must have been one of those songs - you know the ones. They come on the radio, and everyone breaks out into song (like Bonjovi's Livin on a Prayer). As soon as he hit the chorus, the room joined in with him, and I wished I knew the words. Here, though, I've got to disagree with Nicole - I think it still romantic, regardless of the horseraces ("por una cabeza" roughly translates to "by a head" - of a horse).

Continuing the history lesson, the performers of La Ventana paid homage to Maria Eva Duarte de Peron, singing "No Llores por Mi Argentina" (Don't cry for me Argentina, written by Andrew Lloyd Webber for a 1973 musical).

Clearly, we enjoyed our Tango show very much. When we left, a long, long line was forming across the street as a strangely heterogenous group of folks (teenagers and middle-agers alike) waited to get into some club, and I couldn't help but feel a little smug. Next time, I'll revisit our tours and more walking around the beautiful city, as well as updates on the Second Year of Medical School.