Fear. My. Wrath.

This hasn't been the most productive of weekends, but I guess work is getting done. I've gone over the cardiac anatomy that I'll have to know for this upcoming week's dissection, plowed through all of the cardiac physiology notes, and am currently taking a break from working on our DPS (doctor, patient, and society) practical. MERP ran DPS a lot more smoothely - they had us research the methodology of the history and physical, interview classmates who had made-up illnesses, and then hand in what was supposed to be a polished HPI, complete with personal, social and family histories, and chief complaints. Here, instead of anything so dynamic and integrative, we were merely told to come up with a patient on our own (after being told that he or she will complain of "chest pain"), and then, in class on Monday, we are to hand-write the interview, providing both questions and answers. We were told that a good paper consists of 50 questions, so I'm not convinced that they'll read every single one with too much detail. I'll do mine well, and get it out of the way - it's not teaching me how to do a correct history and physical, or enlightening me concerning the differential diagnoses that surround as nebulous a complaint as "chest pain"; it is merely something to do well and get out of the way, so I can go do some cardio questions, review hematopoesis, and preread for all things respiratory. That, however, is not the reason why anyone should fear my wrath.

I consider myself a fairly even-keeled person - I have no trouble looking at both sides of a situation, and can easily place myself in the shoes of another. I try to let most things just slide, preferring not to get too worked up over pittances; they're usually not worth my attention, and I usually forget about them soon enough. Thus, I'm not a wrathful, bellicose individual. There is, however, one thing that will skyrocket me from placid to irrationally infuriated in a matter of milliseconds - being awakened by someone who is being too loud. I don't know what it is; it's like there's a slavering, hellish monstrosity caged behind my eyes, and the over-loud noise that somehow penetrates my slumber hits just the right tones to unlock that cage and set free the monstrosity. I wake up with my blood boiling. Generally, I sit and listen for a while, hoping that it'll die down - rarely does this happen to me, but it happened last night.

I was deep asleep - pleasantly so; Saturday night is one of 2 during the week when I can actually count on a blessed minimum of 8 hours, at least. So at 2:11 am, I hear someone talking at the top of their lungs. One thing about my apartment - sounds seem magnified; the way the balcony walls are built turns them into an effective bullhorn, funneling sound into my room. I'm on the third floor, and it sounds like the dogs running through the grass are just below my window; when people are talking normally on the trail beside my building, I can hear their every word. Last night, I walked out onto my balcony to see how far away this person was, and they were the next balcony over. I slapped my hand against the wall to get his attention, and asked him to quiet down. This guy didn't even respond. So, I very amicably left my apartment, and went and pounded on his door. He must have been still talking, or maybe he didn't hear me - no answer. I went back to my apartment and stewed for 10, maybe 15 minutes, and then went back and pounded on his door, louder this time. My heart was pounding like it was getting me ready for a fight - I could feel my pulse in my head, and distantly recalled something about sympathetic stimulation jacking up one's heart rate (beta one receptors) and clamping down on peripheral vessels (alpha one receptors - ever the med student) in anticipation of fight or flight. I banged on this guy's door a third time - apparently, he didn't want to come out, but I sure as hell wasn't going to go away; I'd already (perhaps irrationally, I know) decided that I'd stand out there banging on his door and keeping him up all night if need be. Third try, the door opens - and I tell this guy that I'd appreciate it if he would never be that loud, this late, ever again. I didn't scream, I didn't shout, but I didn't ask - I think, subconsciously, the "I would appreciate" part is thrown in so that my argument looks good on paper. He stares at me dumbly for a few seconds, and then says "Well I'm here, I'm having a good time, so whatever."

That being the case, the gentleman is lucky it ended how it did. I merely told him what I expected him to do, and left it at that, instead of risking a physical altercation - but that made me so mad I couldn't get back to sleep for half an hour. On Monday, I'm going to go file a formal complaint with the management, and I'm going to lay it out exactly as it happened. I hope they kick him out.

Anyway, I'm going to a study session later on today with Nicole, Glynis (our favorite med student/ PA), and Eddie, a Ph.D in inorganic chemistry who, prior to teaching at some university, worked at the Los Alamos nuclear plant. Needless to say, it'll be interesting, and hopefully quite useful. We start respiratory physiology tomorrow, and a week from Friday there will be a histology lab practical AND an anatomy practical - time to crack my knuckles, grit my teeth, and get down to business.

Call me Sisyphus.

I've been in a funk this week - thankfully it's going away, but it had begun to get alarming. I don't know when it started, really, but studying was just incredibly difficult. Normally, I can find something within the pages to get excited about, but this week has just been tough, leaving me feeling like I'm rolling a huge stone up a hill, with no end in sight. If I was honest with myself, I'd have to say that it probably came about around the same time we began studying the fetal heart - it's like an entirely different language. Normally, I can reason my way through things, creating littel mental hooks that I can use as anchors to integrate things, little bread-crumb trails that help me find my way back to earlier information. Normally, the words I'm learning make sense within the greater context of everything, but in the fetal heart, it's like I'm swimming in an unfamiliar sea. Ductus arteriosus? Bulbus cordis? Septum Primum and Secundum? There's no anchor for these terms - it's just rote memorization. Instead of laying down a hook and just letting my mind follow the trail back to camp, I feel like I'm swimming around in circles until I find a familiar patch of water. Thankfully, though, this next exam will focus heavily on physiology, where those memory hooks and anchors are all we've got.

Maybe I just need more coffee. On a more exciting note, though, I held within my hands several human hearts yesterday. Previously, I had been going through my Rohen-Yokochi-Lutjen-Drecoll atlas, and realized that the coronary arteries are, in a word, breathtakingly beautiful. I'm not kidding - they're absolutely gorgeous. Staring at the heart in my hands yesterday, with ill-fitting nitrile gloves stretched over my palms, that Sisyphean rock got a little lighter.

Dancin'

I talk a lot - I like talking. Most of it is just that, but every once in a while, one of my purposefully farfetched (while at the same time sensical - I'm great at Balderdash) explanations actually pans out and resembles something that may actually be true. Nicole and I did better on this second mini exam, and while we studied hard and changed some things up, I attribute the increase in our success to one thing: dancing. See, about an hour before the actual test was to get underway, we were doing some last minute memory-tweaking in her apartment, the air full of tension and nervous energy. So, to calm myself down, I run and grab my Mp3. player, and start dancing. She pulls out her ipod and starts dancing too - albeit to very different music. So I'm dancing up and down the room, and she's dancing while she does her hair and puts on her makeup, and we're just dancin' to our own beats. A few minutes later, we went out upon the field of battle (a chilly classroom) and conquered the test.

Now, this wouldn't really be noteworthy, but I came across something interesting last night when I was doing my physiology reading. I was going over the control of blood pressure (baroreceptors, chemoreceptors and all), and came across a brief passage that said something along the lines of "the increased cardiovascular output, as in the fight or flight response, when separated from skeletal muscle output, is actually harmful". Basically, it means that when you get nervous and your HR and ventilation go up, and you don't move, it's bad for your health. I think that very clearly supports my decision to dance before every exam or lab practical.

Needlepoint

If I was planning on becoming a surgeon, Thursday would have been like a visit to Disney World (where, coincidentally, my family is vacaationing right now).

I'm just going to throw that out there as a teaser, and pause to admonish myself for not blogging more often - I know I should keep up with it more than I usually do.

Anyway, I got to crack open a chest, literally. Our dissection covered the thoracic organs in situ, and how, you may ask, do we get to those organs? Previous dissections dealt with studying the stuctures of the chest - pectoralis major and minor and their related innervation and vasculature (medial and lateral pectoral nerves and the thoracoacromial trunk). This time around, I got to dissever the serratus anterior from its proximal attachments, revealing the midaxillary line - and then the anatomy professor came around with a bone saw!

By this point, I'm like a kin in a candy store - of course, this in no way resembles a real surgical procedure (they'd just do a thoracocentisis, not a complete removal of the chest wall), but it was fun nonetheless; the goal was to superiorly reflect the chest, so the cuts were made up the sides, and down across the xiphoid process. The part that I REALLY enjoyed, though, came after the professor with the saw had left - he neglected to cut some of the ribs. So do you know what I got to do? I grabbed a chisel and a hammer and went to work!

After that, the whole thing was a little downhill - I learned that lungs in situ are really quite pretty in a healthy individual; they have a texture unlike anything else in the body. My fingertipes are tired of muscles and bone, and my wrists still ached from dissevering fascia from everything else - the compliant sponginess of the lungs was a welcome change. I was a little annoyed, however, that this was an in situ lab - that meant that I couldn't dig around in the mediastinum and look at the heart - I had to content myself with internal thoracic arteries, and loads and loads of pleura.

Anyway, the hi-lite of the day was the suture clinic (schedules were changed around a bit after that last post). All told, I spent about 6 hours in lab, but that last bit of it was pure play. Nicole and I arrived and stood in line outside the lab while the AMSA members set out slabs of skin and little suture kits, slowly admitting students as the tables filled up. The presenter was actually one of the doctors who hovers over my table during dissections - this woman dissects like nothing I've ever seen, so I knew it would be good. She started out showing us how to hold the wickedly curved little needle with our hemostat (and lucky me - I already have several), and only showed us how to do interrupted sutures. All told, I only got in about four sutures; nevertheless, I learned a lot. I may be getting ahead of myself, but I feel like I can do pretty well sewing stuff up - although my sutures were a bit too close. It was so much fun, though!

What could possibly follow that? Well, AMSA had their Women's Fair on Saturday morning in Portsmouth. Some people measured BMIs, some measured blood glucose and cholesterol, Others (like Nicole) taught about breast exams and HPV, and I got to take folks' blood pressure. The sign-pus were funny - the AMSA coordinators (who didn't know that much, I thought) were trying to make very sure that whoever signed up for BP knew what they were doing - but I didn't have to prove my skills when I signed up. Anyway, we arrived to the Calls Centers on the main street in Portsmouth around 10:00am in a light drizzle. They had set up this little makeshift clinic right there on the sidewalk, and had folks just kind of clustered around. (I thought I could have run it a tad better - AMSA leadership may be in my future).

I've come to realize that being half-Jamaican here in Dominica is a plus, and it sure helped when I was taking BPs. Folks just seemed to open up to me, appearing to be very comfortable. Either that, or it was just very obvious how much I truly enjoyed that kind of thing - it was just like when I helped triage at the free clinics in Mexico run by the family practice residency clinic I worked for during a summer in undergrad - once again, it was just fun. I had a few people with high BPs (one gentleman had something like 170/132), and luckily there was a doctor on site to give them some advice. Directly after that, Nicole and I went for ice-cream at a little shop owned by the brother of the dietician here at Ross. Cookies'n'cream after months of no ice cream is like, dare I say, a kiss from God.

Unfortunately, the Easter service left much to be desired. All in all, though, it was what I felt to be an enjoyable, productive weekend.

Mini 2: Finished

They say it's a marathon and not a sprint, but that's a load of nonsense - it's a 26 mile sprint. It's a break-neck, headlong dash to a finish line so far away, I can't even see it - I just know that slowing down isn't an option. It's like I'm being chased by the Wolves of Failure, and in order to keep ahead of them, I've got to sprint like my life depends on it. Mini 2 was on Monday, and I'm back to sprinting. I think it went alright; it wasn't as nit-picky as the first one, and I felt better coming out of this one.

Interestingly, a new study room opened up next to the study space I used to frequent. This is on a big room with rows of single-seater desks - I call it Alaska, or, alternatively, the Caribbean Tundra because it's absolutely frigid. I got some serious studying done - it's a place to concentrate and focus if I ever saw one - it's just that my teeth were chattering the whole time and I could hardly hear myself think.



I love how we don't get so much as a day off - the way things are set up, we have our lab practicals on the Thursday or Friday before the mini-exam. So we're trying to balance studying for the practical with studying for the mini (they don't overlap at all, I don't care what anyone says). It's rough, especially since the mini is on a Monday - classes start again Tuesday morning. After the last mini, I didn't take a break at all - the day of the actual test, I was back at the study space, learning the clotting cascade. This time, though, I allowed myself the pleasure of some merlot and chocolate cacke at Tomato's with Nicole - and then came Tuesday morning's introduction to the cardiopulmonary system.



Oddly enough, I think I'm going to enjoy the "rough-stuff" - cardiac and pulmonary physiology. It's not that I'm particularly good at it - but since I've had it in MERP, I've gotten a bit of familiartity, and it makes sense. The thing I kind of like about physiology is that it can't be limited by rote memorization, but rather is exemplified by application. Maybe I'm just telling myself that it'll be fun...

Speaking of fun, though, I have an AMSA (American Medical Student Association) suture clinic today, and I'm really looking forward to it. I figured my dues should get me more than a t-shirt, and I should start acquiring skills that might actually be useful some day. (Not that clathrin and cardiolipin aren't useful...they're just.....you know.....not associated with anything I might ever see as a doctor). I don't know what to expect - I've only spoken to one person who had done the clinic, and it sounds like something I'd really enjoy - Lord knows that if I closed up a surgery with the stitching skills I've got already, I'd better get myself a fantastic lawyer.

We're supposed to be getting some interesting weather tomorrow; apparently, a storm or something is going to roar our way, causing waves of up to 15 feet. Now, for all the storms I've heard about, I've seen precious little in my time down here except for the occassional rain. I don't want to jinx myself, but I'd like to see a good Texas-sized thunderstorm - the lightning around here must be fantastic with only the mountains in the background.

I try not to stress - it's just not who I am. Here's a picture from yoga on the beach.

Complaining is something that we're all prone too - we piss and moan when things don't go our way. Justified or not - logical or not - we're all going to vent and gripe about things we disagree with. Some of us do it more graceully and tactfully than others - Nicole is fond of prefacing her complaints with a diplomatic "Now I'm not a doctor, but in my humble opinion..." I am not so nice. My complaints usually begin with "This is the dumbest thing I've ever heard of", or, if I'm feeling prim and prope, "I can't believe they're doing it so poorly". Case in point: the physiology department here. Now, I can complain about everything, because, let's face it - no one's perfect, but the physiology department has taken disorganiation to astonishing new heights.

It only makes sense to me, that in order to learn things, one should proceed in a logical order. For example, when learning about muscular contractions, one should begin with skeletal muscle, and then move on to smooth muscle. Cardiac muscle has its own differences and qualifications, so cardiac contractions should be taught within the heart as an organ system, building on a pre-existing foundation of familiarity with contraction in the other muscles. "Nonsense!" says Ross' physiolgy department! "We're going to start off with cardiac contraction, without explaining anything about the conduction system - and then we'll jump quickly to skeletal muscle contraction, then back to cardiac muscle, and we'll jump around between the two until time requres we stick in smooth muscle." The reason my complaining is blunt (bordering on offensive, although I'll keep it to myself, because, as Mom says, those Phd.s can make life harder for me than I can for them) is due entirely to the fact that, you know what? I could do it better. I realize that part of this organizational system may have nothing to do with any logic and may in fact be related to when some big-wig share-holder (because my med school is a for-profit med school) decided they wanted to take vacation, and pushed a lecture series back a few days.

To add insult to injury (because I'm personally offended by this - really, I am), this morning the physiology department decided to start us off with ECGs. I mean come on! Have we done the conduction system? Sure - at the beginning of the lecture, we got the quick-and-dirty low down and SA and AV node potentials vs. ventricular potentials (guess it wasn't that important), but what's the rush? Once again, I feel that if it were up to me (or, say, any particularly bright 5th grader), the organization of this particular subject would have proceeded much more smoothly. Seriously, the heart is complicated enough without jumping around between the big concepts. I truly feel bad for my classmates who don't understand the arterial system (it's not like we've had the anatomy of the heart, and it's not like we all have the benefit of MERP or being the offspring of an interventional cardiologist - this is a purely altruisitic rant).

I hope that, now, my complaint against these Ph.d's perhaps makes a bit more sense. It's interesting to note, though, that although the other departments may employ professors who write questions that lumber through exams like vicious ogres, completely blind-siding us as our number 2 pencils tremble in our fingers, they're at least organized. The physiology lecturers aren't bad per se, they're just throwing around concepts like it doesn't matter. You want to just teach a little bit of it? Fine - I know it doesn't really affect you - you'll get paid either way; but please have some sympathy for those of us who'll actually treat patients. That reminds me of a funny quote from, surprisingly, one of my anatomy lab professors - "Don't just learn this to learn it, you're actually going to have patients some day - you're not doing this to be anatomy Ph.d's; you're learning it to be useful." Amen to that.

*whew* I feel better now; I can go back to taking notes in my physiology class now that I've gotten that off my chest. Guess what we're learning to do now? That's right, count heart rate based on ECG paper.....because, even though a large box is 0.2 seconds, you never know.... I guess they're right; I'd rather learn how to count than to understand the physiology of pacemaker cell depolarization.

Darkness

An interesting thing happened to me last night, that really made me realize that I'm in an entirely different country. Nicole and I had just finished a hard day's work of studying at our favorite study space, and were heading back home. Quite suddenly and shockingly, everything went black - literally, profoundly black. We were suddenly plunged into such an utter, complete, stygian blackness that I was stunned for a moment. After a few moments of shock, I had to look up at the stars to see that I actually hadn't been struck blind. Everywhere around us had been plunged into a blackout of such impenetrable and complete darkness that the two or three seconds in between the actual blackout and the automatic engagement of the emergency generators seemed to drag on forever.

Blackouts in America aren't like that - there's always a streetlight living off of city power, or perhaps the other side of the road remains lit - at the very least there are car headlights somwhere - but never before in my life have I see it as dark as this. I didn't know the world could be that dark. Anotehr interesting thing is hat it was aboslutely silent as well - no sound, no light at all. Everything just very suddenly went very still and dark. I thought it was pretty cool, actually

In other news, I have a histology lab practical a week from today, and then, a week from Monday, we'll have our second big exam. I've come to realized that this is going to be all I do for quite a few years to come, and so I've enlisted my little brother to watch movies and read books, that I might live vicariously through him (as you may think you're doing through me, here on this warm, Caribbean island, taking pictures of brilliant sunsets. What you don't know is that I have my nose in my nose half the time, and the other half of the tim I'm splitting it between class and the anatomy lab).

Speaking of which, I had the pleasure of dissecting out the anterior leg yesterday, and it just wasn't as cool as it had been before -perhaps the lab has lost its luster. After a while, muscle looks like muscle. It is, however, a little humbling and surprising to realize that, after searching the whole time for the dorsalis pedis, it's right there on the top of the foot where it ought to be (and was just pretending to be a nerve). I should have followed it down from behind tibialis anterior like they suggested, but oh well - you live and you learn.

Fearfully and Wonderfully made

Here is my second home - this is the study space at which I spend almost all of my time. I should have taken the picture from the path to the school, because it would have cut out the telephone pole, but I didn't think about it - perhaps I'll replace it later. On another note, I perhaps should apologize to some of the Ph.Ds who may have been offended by my post-exam rant - I know they work hard and are respected members of our academic community. However, during a TA session in the anatomy lab today, Nicole started to not feel so well. She went outside, got some water, and sat on the steps. Apparently, a professor walked by, glanced sideways at her, and just kept on going. While I find it a little strange that they didn't stop to ask if she was alright, I'm not really surprised; they're not real doctors anyway.

There is a street, here in Dominica, called Moo Cow Trail. As you can probably tell by now, in addition to being populated by med school students, Moo Cow Trail is also home to many of the island's bovine residents (whose amorous lowing often keeps my classmates awake). It would appear that late February - early March is vacation time in cow-country. The cows have relocated from their trail to the grassy hills below my balcony, where they have a lovely view of the Caribbean Sea, and can rub elbows (hoofs?) with students returning from class. This one had horns, though, so I didnt' want to get close enough for a really crisp picture.



It's Sunday - I'm going to preach a bit.

My favorite Psalm (maybe my favorite chapter) in the entire Bible is the 139th Psalm. It's a somewhat atypical praise of God's goodness from David - instead of exalting the Lord for His faithfulness and mercy, David basically praise Him for two things - God knows us intimately, and planned out the human body with complexity and love. I've always liked it - the last two verses are my favorites, but the longer I'm here at medical school, two particular parts seem to become more true every day - the "fearfully and wonderfully made" portion, and the part in which David says "You are everywhere" Here it is:

For the director of music. Of David. A psalm.
1 O LORD, you have searched me

and you know me.

2 You know when I sit and when I rise;
you perceive my thoughts from afar.
3 You discern my going out and my lying down;

you are familiar with all my ways.
4 Before a word is on my tongue

you know it completely, O LORD.
5 You hem me in—behind and before;

you have laid your hand upon me.
6 Such knowledge is too wonderful for me,

too lofty for me to attain.
7 Where can I go from your Spirit?

Where can I flee from your presence?
8 If I go up to the heavens, you are there;

if I make my bed in the depths, [a] you are there.
9 If I rise on the wings of the dawn,

if I settle on the far side of the sea,
10 even there your hand will guide me,

your right hand will hold me fast.
11 If I say, "Surely the darkness will hide me

and the light become night around me,"
12 even the darkness will not be dark to you;

the night will shine like the day,

for darkness is as light to you.
13 For you created my inmost being;

you knit me together in my mother's womb.
14 I praise you because I am fearfully and wonderfully made;

your works are wonderful,

I know that full well.
15 My frame was not hidden from you

when I was made in the secret place.

When I was woven together in the depths of the earth,
16 your eyes saw my unformed body.

All the days ordained for me

were written in your book

before one of them came to be.
17 How precious to [b] me are your thoughts, O God!

How vast is the sum of them!
18 Were I to count them,

they would outnumber the grains of sand.

When I awake,

I am still with you.
19 If only you would slay the wicked, O God!

Away from me, you bloodthirsty men!
20 They speak of you with evil intent;

your adversaries misuse your name.
21 Do I not hate those who hate you, O LORD,

and abhor those who rise up against you?
22 I have nothing but hatred for them;

I count them my enemies.
23 Search me, O God, and know my heart;

test me and know my anxious thoughts.
24 See if there is any offensive way in me,

and lead me in the way everlasting."

Where can I go from your Spirit? Where can I flee from your presense? I don't know, but Dominica isn't one of those places. God's with me here too - in the study spaces when I'm trying to cram everything into my head, in the lecture hall when I'm taking notes, and in the anatomy lab, when I'm dissecting and studying. It's in there, more than anywhere else, that I see how fearfully and wonderfully made we are. Did we really need the flexor retinaculum to keep our wrist tendons from bowstringing? Was it absolutely necessary for our major arteries to be deep in our limbs, protected by muscles? Does the hand have to so intricate and complex? I don't think any of those are necessary, but I think that God loved us so much, that even before He created us, He planned to make us incredibly intricate, fully able to enjoy His creation. It's almost laughable to me that some people believe that millions of years of beneficial mutations got us where we are. The complexity of the clotting cascade alone is amazing - it's a system of checks and balances that makes the American government look like children playing in the sand. I can't believe how people can look at a handful of 15 (at least) different factors and proteins for blood clotting alone and ascribe it to chance. I prefer to believe that God planned it that way - it just makes more sense.