You can live without a stomach

This week we started dissecting the abdomen. We cut through all the layers of muscle holding our abdominal wall in place and protecting our organs, including the rectus abdominis (yeah six pack!), and several layers on the side like the external obliques, internal obliques and transversus abdominis muscles (yeah new words!).


Today, we started looking for the liver, stomach, spleen, pancreas, gall bladder and the veins and arteries running to and from these organs. Well.... to make a long story short: SHE HAS NO STOMACH! Crazy. Luckily, a wonderful thoracic surgeon happened to be in lab today and described the full gastrectomy that removed her stomach, spleen and the greater omentum that covers these organs. The pictures below helps to explain how the surgeons removed her stomach and hooked up her esophagus to her small intestine. Needless to say, we had a rough time in lab identifying all of the abdominal viscera because everything was shifted, reconnected and unexpected!




Here is a blog entry from a person living with a full gastrectomy: Living with a Gastrectomy: One Researcher's Experience.

Hey Med School! I thought that was you!

Thank god for clinical correlation lectures, teamwork in the anatomy lab, simulation centers, and observations of the patient interview! I'm writing this today... but it was actually yesterday that made me say, "YES! This is why I'm here!" Everything we had been learning about and dissecting in the thorax started to make sense and became relevant medically.

Dr. Yang, a top thoracic surgeon, did some show-and-tell about common, and crazy, surgeries of the lungs and heart. He gave the history of the surgery (they used to fill an empty lung sac with ping pong balls) and then gave us the run down of how the problems are fixed now. The amazingly cool part was that I followed what he was saying!!! I'm sure he didn't use every medical word he could have - but he did describe how the internal thoracic artery running just laterally to the sternum can be removed and used in coronary artery replacement surgery to repair the blood vessel that supplies blood to the heart muscle itself. Anyway... Dr. Yang's lecture made me feel like I was finally learning something :)

Working on any team is a challenge, and in anatomy lab, we are working on a team standing over a cadaver, dissecting tiny nerve in a rather small thorax. Sometimes there are too many cooks in the kitchen (yes, we wear white aprons!). Yesterday (and actually today also) we worked so well together! We found and cleaned off the aortic arch and the branches to the rest of the head and neck, we found both vagus nerves, the carotid arteries, and many other really cool structures! The excitement and cohesion were palpable (as were the arthritic vertebra).

The simulation center did not disappoint. First we were taught and practiced CPR on an adult, child and infant mannequins (compressions should be 100 times per minute, or to the song Stayin' Alive, demonstrated here in The Office). Then we saw how use a laryngoscope to insert a breathing tube into a patient along with the fiberoptic bronchoscope that's used to visualize a patient's trachea, bronchi and lungs. The last station introduced us to Sim Man, a breathing mannequin that has a medical problem and responds to your attempt to fix it. He had a collapsed lung and we practiced inserting a needle between the ribs (intercostal spaces) to allow the air to escape! As of today, I can't imagine doing that to an actual patient in distress, but Sim Man was good practice :)

Lastly, we observed a doctor interview a patient to learn proper communication techniques. This completely rounded out the day that made med school real. This was a 57 year old woman with bone marrow cancer. She told her story from beginning to end over 45 minutes. It was clear that she placed a lot of trust in Dr. Shochet, and that she respected him. I feel grateful to have these experiences to help me learn how to be a compassionate and competent doctor.

And after a long day, I even got some quality time with my husband! Of course, knowing that I hadn't yet showered after spending a good 4 hours in the anatomy lab, he did say, "Um, you smell a little bad..."

Abnormalities of the chest

We watched this video in class today! Which was funny... but then I found the surgery to fix it... not as funny, but still fun :)

Why am I dissecting a human?

Apparently I should be practicing on a sea turtle.

Today I used a bone saw to cut through the ribs and sternum and removed the rib cage. We then removed the lungs. Tomorrow: heart.

Anatomy

I did not sleep well last night. Sweat was pouring off of me, I was uncomfortable, and I couldn't stop thinking about what my first day in Gross Anatomy would be like. A human cadaver. Lots of human cadavers in the lab... 24 dead bodies. What would it smell like? Would I be able to cut into the body?

"This will be your first patient. This person wanted you to learn from their body. They will teach you more than any textbook every could." - Dr. T

After a brief lecture about the thorax and what to expect in the thoracic cavity, we changed into our scrubs and headed to lab. The 6 of us stood around our body - it was covered in a green plastic sheet, but I knew underneath was a clear plastic bag, and the body was shrouded in cotton cloth. What parts of the body do we think of as being most "human?" The face. The hands. The feet.

I am nervous, but I am so grateful to have this opportunity, to stand where few can and to learn. My responsibility is to this patient, to my partners, and to my future patients.

"Your responsibility is to learn from this body the things that will help to save the lives of other people." - Dr. K

As a group, a medical team, we started by uncovering the feet and then the hands. We observed the age of the skin and the joints. The coloring was off. Preservatives. You could smell them.

We uncovered the face. This was the strangest thing I've ever done. It wasn't scary, but it was so unusual that it was only natural to feel very uncomfortable. This person is Asian. Small in stature, thick lips, heavy creases around the eyes. I thought about our trip to Thailand, Cambodia and Vietnam - this person could have lived there. It became real.

Our group collectively guessed this person to be a 75 year old male, but after uncovering the entire body we were surprised to find a female. Her knees were bulging: arthritis. She did not have much fat at all - her legs and arms looked pretty good, even toned. Dr. K then reveiled that her age was 91! 91! I hope I look that good at 91!

We broke into our groups of 3 and I stayed to disect the breast, skin and pectoral region with 2 partners while the other group members went to learn about imaging. Then we flip flop. We will do this every day for the next 8 weeks. The three of us will teach the other group what we learn in lab and vice versa. We will all disect every day, for about an hour and a half each day - 3 hours total between both groups. We will learn about the entire body: every organ, muscle, nerve, vessel and bone.

Today we uncovered the pectoral muscles (major and minor) and found lots of great nerves, veins, arteries and connective tissue. We saw the striations of the muscle fibers and found where they connect to the bones.

The pectoralis major connects to the humerus to allow us to lift our arm. It's true. I saw it!

Bones

This week has been wonderful! I'm having a blast getting to know the amazing, accomplished and impressive students that I'll be learning with over the next 4 years. After taking some time to reflect, I'll write a longer post about the Health Disparities Intersession we've been exploring this week (the health issues in the East Baltimore community, how to think cross culturally, etc)... but I just wanted to mention the box of bones that is now in our living room.

I was planning to walk home on Tuesday, but instead I had to call Matt to come give me and my bones a ride :)

Budgets

Following the "Live like a student now" theme, Matt put together a budget and subsequent spreadsheets that will help us follow that budget. We are going to be "proactive" as opposed to "reactive."
Then he printed them in color and put them on the refrigerator. And apparently they will be updated, printed and re-posted on the fridge each Tuesday. Ladies, if you can, marry a financial planner. And if you can't, you can borrow mine for the day. He'll make you nice spreadsheets to keep your spending under control.

Year 23

On Monday I'll start my 23rd year of school. First through 12th grade was 12 years, I went to kindergarten for a year, I actually went to pre-school for two years (my best friend and I were jealous of our older sisters that got to go a year before us... so we went with them a year early. My best friend was our class valedictorian - so I guess that extra year of pre-school paid off!). Then undergrad for 4 years, a masters program in teaching for 2 years, and on the day I received my masters diploma in the mail I started my post-bac pre-med year. Now after exactly one year off, I'm starting my 23rd year of school.

I think I keep signing up for school because I'm good at it, I know what to expect and I like highlighters and sticky notes. It's not the first time this has occurred to me, but it's the first time I'm verbalizing it. I really hope I'm good at being a doctor because I can't keep going to school forever. Plus you have to pay someone else to be a student, and it would be nice to do something that pays me instead.

HealthCare.gov

In preparation for my med school interviews last fall, I memorized several facts about Obama's health care reform plan. I'm not about to claim that I understood all of what was being discussed, but I wanted to be able to address any interview questions such as, "What do you think of the discussion on health care reform?" In fact, one school asked me, "How would you solve the health care access problems we are facing?" Wow.

Obama's new Affordable Care Act was signed on March 23, 2010. This (government sponsored) website, HealthCare.gov, gives some great information on everything from understanding the new laws, outlining the time line in: "What's changing and When", and helps you to find insurance options based on your state and specific family situation.

One specific part of the website that caught my eye discussed how this Affordable Care Act addresses the Health Disparities I witnessed as a Baltimore City School teacher, I see every day as a clinical research assistant, and that will become a priority as I learn to care for the people of East Baltimore as a medical student.

I wanted to cut and paste sentences from the article, but quickly realized that I would end up copying the whole thing. Every point made and change that will take place is important! I tried my best, but you might as well just read the article.

• "Low-income Americans, racial and ethnic minorities, and other underserved populations often have higher rates of disease, fewer treatment options, and reduced access to care."
• "...minority communities experience higher rates of illness and death for chronic diseases such as diabetes, kidney disease, heart disease, and cancer. Because infant mortality and post-birth complications are also higher in minority and low-income groups, the law includes new funds for home visits for expectant mothers and newborns."
• "[the act] strengthens cultural competency training for all health care providers."
• "Health centers serve an estimated one in three low-income people and one in four low-income minority residents. ... health centers to double the number of patients they serve. Combined with investments made by the American Recovery and Reinvestment Act, the new law will support 16,000 new primary care providers."
• "Women will no longer have to pay higher premiums because of their gender. New funding will be available to collect information on how women and racial and ethnic minorities experience the health care system, leading to improvements that will benefit these groups."

I admit that this article came from a government sponsored website. I also admit that no where did the site explain the actual logistics of HOW this was all happening. For example, we already have a shortage of primary care providers, so how exactly will the law support 16,000 new primary care people? Maybe there will be an incentive to become a primary care physician, such as "we'll pay all of your med school debt if you become a pediatrician."

There are obviously many other parts of the law that change the health care scene for young adults, those with Medicare prescription drug coverage, early retirees, those with pre-existing conditions, and many other groups. Plus a focus on prevention is a huge step forward in my book!

I'm really interested to hear what others (specifically my family and friends) have to say. I do not know enough about health care politics and this is clearly a hot topic to debate.

Defense

Med school is going to kick my ass and I need to be ready! A few weeks ago I decided to start preparing my body's sleep schedule for medical school. For the past year I've been getting up around 7:20, leaving by 8:20 and getting to work by 8:45. But, after getting my class schedule in the mail, I realized I will have to physically be in a classroom, taking notes, and thinking at 8am. So... with one month of summer left, I started getting up at 6am. That lasted exactly four days.

This past Monday, with two weeks to go before school, I started the early morning wake up routine again. And I'm exhausted! This is awful because (a) my dad and mom work an average of 15 hours a day or more in the summer, (b) my husband is out the door by 5:45am on most days, and (c) when I was a teacher I was regularly up by 6 and at work by 7:15.... and now I can't manage to get up at 6am without feeling tired by dinner time.

I'm determined not to press the snooze button or take any naps at all in the next week and a half. My body needs to learn to fall asleep by 11 and get up by 6 - and that's just the way it's going to be!

Then I found an excerpt from a book published by the NIH that lists some misconceptions about sleep:

Misconception 1: Sleep is time for the body in general and the brain specifically to shut down for rest

Sleep is an active process involving specific cues for its regulation. Although there are some modest decreases in metabolic rate, there is no evidence that any major organ or regulatory system in the body shuts down during sleep. Some brain activity, including delta waves, increases dramatically. Also, the endocrine system increases secretion of certain hormones during sleep, such as growth hormone and prolactin. In REM sleep, many parts of the brain are as active as at any time when awake.

Misconception 2: Getting just one hour less sleep per night than needed will not have any effect on daytime functioning

When daily sleep time is less than an individual needs, a "sleep debt" develops. Even relatively modest daily reductions in sleep time (for example, one hour) can accumulate across days to cause a sleep debt. If the debt becomes too great, it can lead to problem sleepiness. Although the individual may not realize his or her sleepiness, the sleep debt can have powerful effects on daytime performance, thinking, and mood.

The biological clock that times and controls a person's sleep/wake cycle will attempt to function according to a normal day/night schedule even when that person tries to change it.

Misconception 3: The body adjusts quickly to different sleep schedules

The biological clock that times and controls a person's sleep/wake cycle will attempt to function according to a normal day/night schedule even when that person tries to change it. Those who work night shifts naturally feel sleepy when nighttime comes. A similar feeling that occurs during travel is known as jet lag. This conflict, set up by trying to be active during the brain's biological nighttime, leads to a decrease in cognitive and motor skills. The biological clock can be reset, but only by appropriately timed cues and even then, by one to two hours per day at best. Problems resulting from a mismatch of this type may be reduced by behaviors such as sleeping in a dark, quiet room, getting exposure to bright light at the right time, and altering eating and exercise patterns. Because humans function best when they sleep at night and act in the daytime, the task for a person who must be active at night is to retrain the biological clock (by light cues).

I'm not drastically changing anything... like trying to stay awake at night and sleep during the day, so I think I'll be ok! But I hope I'm not developing "sleep debt" and my body really is ok with functioning on 7 hours!

"Live like a student while you're in school...

... and you won't have to live like a student later."

As Matt and I were filling out the endless financial aid paperwork, the always super fun FAFSA form, student loan promissory notes, and entrance counseling online classes, we found a ton of information on medical school and debt. We punched numbers into this loan repayment calculator, searched Federal Stafford Loan interest rates (6.8% for graduate school), and made spreadsheets detailing living costs, tuition, books and lab fees. Ok, he made spreadsheets :) I'm planning to write a more complete post on the finances of medical school, but the point is, medical school = debt. But, I'm one of the lucky ones because my husband has a good job and we can decrease our loans by living off of his salary! I still need to pay for tuition... but I won't need to take out loans for rent, cable, or electric.

This past weekend we took the first step as a "single income family" and moved from a lovely rowhome with 900 square feet of space to a brand new apartment with a footprint of 550 square feet. When we told our rowhome neighbor we were moving he said, "Well you can't get much smaller than these houses." In unison Matt and I replied, "yeah... ya can." We spent the weekend putting boxes into three piles: apartment, goodwill, mom & dad's basement (they thought they got rid of Matt's things when he moved out... sorry!). It will be like Christmas when (in 4 years) we open the boxes of all the things we don't have room for now! By getting creative with storage (like an ottoman you can put blankets and pillows in), putting up shelving in closets (all 2 of them!) and agreeing to remain organized and put things away, we are transforming into apartment dwellers. And I must say, I love our new place! It's cozy and comfortable and us.

Ok, so it's not exactly the college lifestyle :) We still need to get pictures on the walls, but our dishes and furniture match, there are no stains on the carpets or empty beer bottles or pizza boxes to trip over. It's a little tight, but we are making it work now so we don't have crazy debt later. Thanks to Matt for "living like a student" with me.