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April 29, 2001 
Here I am only one year until graduation. I'm almost done with the infamous 3rd year. I've completed rotations in Surgery, OB/GYN, Psychiatry, Pediatrics, and Family Medicine. Currently, I am 1/3 through my Internal Medicine rotation. My newest dilemma is trying to decide on a career path and residency program. I seem to change my mind as often as the weather changes in Texas (often). It's such an important decision. I don't want to make the wrong one after all this time and money I've spent on my education! So far, I've liked Internal Medicine and Pediatrics the best. Next year, I'll take electives in Anesthesiology, Cardiology, Surgical Intensive Care Unit or Medical Intensive Care Unit, Pediatrics, Family Medicine, Internal Medicine, Neurology, & Radiology. On Monday, I start a Hematology-Oncology elective.
Spring 2000
Another, "I will never forget this" experience. I watched an autopsy. I wouldn't want to be a Pathologist (that is the kind of doctor that does autopsies) or anything, but it was still interesting to be there. My patient was a 46-year-old African-American prisoner that had passed out in his cell. He didn't have a doctor, so the cause of his death was totally unknown. The first thing we noticed was that his legs were swollen (edema). We also checked over his whole body for needle marks or bullet wounds. Next the morgue techs (who do most of the dirty work) ripped open his chest and abdomen. Next, we inspected the organs "in situ" (just sitting their undisturbed). Next, we took out each organ one by one and inspected and weighed them. His heart was almost twice as heavy as it should be. He also had fluid in his lungs and abdomen. So far, everything we found point towards heart failure.
Heart failure is when the heart (for some reason) is unable to pump the blood through the body. The blood that was suppose to go into your body from your lungs gets stuck there because your heart can't muster up enough power to push it on through. Therefore, your lungs and heart get all dilated and full of blood/fluid. Next we had to find out why is heart wasn't working. For instance, it could have been a heart valve problem, a lung problem, or a heart muscle problem. Turned out that his problem was a heart muscle problem. When we dissected his heart, we found all 3 of the main coronary blood vessels were 60-80% stopped up. One of the marginal branches was even 100% occluded. The atherosclerosis was so bad that you could see it with the naked eye. It looks yellow (which makes sense because it is made up of fat, cholesterol, and goop). We could also see a white scar. In order for a scar to be formed, it must have been at least 8 weeks since the heart attack in that area. There could have been a more recent heart attack, but you have to see that under the microscope. So, from all those clues, we decided this man had coronary artery disease leading to several heart attacks (old ones and new ones) that compromised the pumping ability of the heart leading to the dilation of his heart, the fluid in his lungs and his legs. Eventually, the broken heart just goes, "I can't take it anymore!" and just stops. Since this man was young, not overweight, and appeared muscular/in shape, he did not fit the stereotype for heart disease. He probably had a genetically high cholesterol level. Moral of the story: get you cholesterol checked.
The second autopsy was a woman who was in a car accident 3 days prior. She had walked out of the emergency room just fine. Then she noticed numbness in her right arm followed by mental symptoms. Turned out, the sheer force of the other car ramming her jerked her head so hard that it cause a nick in her left carotid artery (the artery going to your head). A small nick in an artery sends off this huge cascade of events leading towards a bid old clot. Her body thought it was doing the right thing by making a clot, but it cut off the blood to her head! The left side of your brain controls the right side of your body, so that is why she had numbness in her right arm. The mental symptoms were also from the lack of blood to the brain. The driver that hit her had a suspended license, and he had run the stop sign. The detective from the police department was there to witness the autopsy. The driver of the other car will probably go to jail because of the clot we found in the lady's neck. I didn't get to see the damage to her brain because I was looking at the next case.
The 3rd autopsy was a man who had had a stroke. They take the brain out in all autopsies, but this one was pretty gross because the stroke destroyed half of it! Oh, I forgot to mention that they look for bruises on the inside of your scalp! Sometimes it is hard to see a mark on the outside, but you never miss it on the inside. This man with the stroke and the heart attack prisoner both had mild bruises on the inside of their scalps consistent with a fall not a whack over the head.
July 1999
This month, I did a preceptorship in Family medicine. I had the awesome opportunity to shadow a family physician that concentrated in obstetrics (delivering babies) and gynecology (women's reproductive health). First, I shadowed the receptionist (I worked as a receptionist in a Pediatric office for a year and a half, so I was okay there). Next, I spent some time with the records and billing people. This experience (and the time spent working as a receptionist) help bring home the message that the office staff is the most important part of a medical office. The patient spends more time with these people than they do with the doctor. If you have good office personnel, they will be good to your patients, and your patients will be happy! I had a great time and the whole office was super friendly.
The most exciting part of this preceptorship was watching/helping at 3 deliveries! Just as a bonus, two of the deliveries happened to be on my birthday! My preceptor would call me at home when she was expecting a delivery. I would jump out of bed and put on my scrubs and drive to the hospital. Once at Labor and Delivery, I would check on the patient with my preceptor and "scrub in" when the time came. The most difficult part was putting on all the gear: hat, mask, gloves, shoe covers, huge backwards jacket thingy, and gloves! Once suited up, I was able to reach "in" and feel the baby's head. I also was able to cut the umbilical cord. My preceptor also handed me one of the newborns not even 2 seconds after it was born. My only responsibility was to safely carry the infant to the table where the nurses quickly went to work. I also helped the preceptor with the stitches the mom received after the delivery. Deliveries are exciting and very messy! Picture a child coming out of the end of a waterslide at a water amusement park. That is what it looks like when a baby is born!
Unfortunately, I had to cut my experience short due to my own surgery. My preceptor actually assisted on my surgery, and then she and her staff visited my in the hospital the next morning!
June 11, 1999
A preceptorship is a great opportunity that is available the summer after your first year of medical school. The medical student spends 4 weeks shadowing a physician in one of the primary care fields. You can choose between internal medicine, family medicine, and pediatrics. You can also elect to follow a physician in a rural area. For my first preceptorship, I shadowed an Internist here in Lubbock. I was exposed to areas of medicine such as nursing home & elderly care, management of patients with multiple diagnoses, and preventative medicine. I saw many patients with emphysema, arthritis, migraines, high blood pressure, heart failure, thyroid disease, diabetes and much more.
Each visit was systematically approached. First, the nurse would record the chief complaint. Next, the doctor would let me take a history of the patient's present illness. This is obtained by asking open-ended questions that allow the patient to elaborate on his/her symptoms. This information is recorded on the patient's chart under the heading "subjective." Next, I would document parts of the physical exam in the chart under the heading "objective." Most everything documented in the chart has an abbreviation. For example, HEENT stands for Head, Ears, Eyes, Nose, & Throat. I would look in the patient's ears and nose for signs of infection with an otoscope. With the light from the otoscope, you can also look at the throat. Say, "ahhh!" Next, I would look in the patient's eyes with an opthalmoscope. With an opthalmoscope you can see the patient's retina and overlying blood vessels. I would also palpate (use hands and fingers to examine) the patient's neck in order to check for swollen lymph nodes or an enlarged thyroid.
I also listened to the lungs and heart with my stethoscope. I was able to hear crackles and wheezes a few patients' lungs. Crackles (also called rales) are discontinuous popping noises produced by air entering bronchioles or alveoli that contain serous secretions (in other words: fluid in the lungs). Crackles may be a symptom of congestive heart failure or pneumonia. A wheeze is a low or high-pitched sound that can be heard on inspiration and expiration. A wheeze is caused by the flow of air through a narrow airway. A wheeze may indicate a bronchospasm, inflammation or obstruction of the airway, asthma, and chronic bronchitis. After 4 weeks of trying, I finally heard a heart murmur. It sounds like a muffled "swoosh" rather than the concise "lub-dub" of a normal heart beat. Heart murmurs are rated on a scale of I (soft) to VI (loud) by their intensity.
I also watched several ECG's (electrocardiogram: a test that involves sticking little electrodes to the patient's test in order to read the electrical activity of the heart. ECG is also commonly interchanged with the abbreviation EKG from the German translation). I learned to draw blood (venipuncture), and I took blood pressures with a sphygmomanometer (blood pressure cuff) as well. I watched several joint injections (arthritic joint is injected with a steroid to lessen the inflammation and an analgesic to lessen the pain). I watched the nurse start a central line. A central line is a piece of tubing inserted in a central vein (the subclavian vein in this case) so that fluids and medicine can be administered to the patient without having to do numerous peripheral sticks.
There was another aspect of the experience that is hard to document but is just as important. There were many hugs exchanged over bad news and good news. There was the time one of the doctor's elderly patients decked out in swinging clothes from the sixties brought in his keyboard and improvised a jazzy tune dedicated to her. There was the endless parade of drug representatives that came through the office bearing drug samples, pens, and (most importantly) food! There was a time the doctor had bad news about lab results showing cancer. There was also a couple of deaths. There were miracle patients that beat the odds and recovered from severe heart attacks and lung transplants. There was laughter, tears, sighs of frustration . . . it's hard to put it all into a journal entry.
May 12, 1999
I wrote this poem for a writing assignment near the end of my first semester.
12/3/98
My Cadaver
January 8, 1998 is the day he died
He was only 45
I am sure he had a family
a wife
children
It was cancer
full head of hair
black as night
soft
wavy
and a thick wiry beard
I am sure somebody misses him
I held his hand
cold
I held his heart
cold
industrial corrosion worker
fingers worn
what kind of life was his?
worked hard
lived hard
heart swollen
belly large
square face
his cheeks prominent
nose pointy
his left side was overtaken with cancer
the cancer was pink and fleshy like a hard rubber ball
a large railroad track scar across his abdomen
missing a kidney
his intestines were full
brain squishy
not just a brain
his brain
his thoughts
his person
his essence
what makes a person?
spirit
soul
personality
I picture him in plaid button down shirts
lungs pink
fat yellow
slippery
his liver looked like a large pirate's hat
eyes closed
resting
slight smile
pleasant peaceful expression
what was his last day like?
what did he say . . . goodbye?
could he be me?
March 29, 1999
I have one exciting thing to report: I got my first pimp question correct (pimping is when a senior person asks you a question on the fly). My preceptor (a doctor I follow around a couple of afternoons a month) asked me, "what is the life span of a red blood cell?" The correct answer is 120 days. There is a test called the A1C that measures the amount of glucose that adheres to a person's red blood cells. This number gives the doctor an idea of how the person's blood sugar levels have been for the last several months (a red blood cell lives a 120 days so this test reflects blood sugar levels for the last 120 days). For instance, if a diabetic patient claims to have consistent blood sugars below 120 but the A1C is in the double digits, the doctor knows that the blood sugar levels actually have been higher.
January 24, 1999
It has begun again, the madness of medical school. So far, I like physiology the best. We finished the cardiac section on Friday, and we start the renal section on Monday.
December 12, 1998
Wow, I can't believe the semester is almost over. It has gone by so fast. I will try to write in this journal more often next semester. I don't think anything will top the anatomy experience, however. Next semester's class schedule will include neurosciences, Physiology, and Concepts in Community and Ambulatory Care. We have a required text list of a few hundred books. I will be lucky to get out of the book store under $400. I had my best round of exams last week. Maybe I am finally figuring this medical school thing out.
November 7, 1998
My second set of exams is over! Phew. Last week we dissected the abdomen. It was pretty interesting. The liver (as I learned in biochemistry and histology) is the wonderful multi-purpose wonder organ. When I was reading about its many functions, I felt like I was reading the transcript to an infomercial. We also learned about this disease related to hemoglobin that makes your teeth glow in the dark. I wonder if I will ever see any patients with glow in the dark teeth. These patients also become sensitive to the light and consequently tend to only come outside once the sun has set. Another sympton of this disease is the growth of extra hair in normally non-hair posessing areas. Sounds like a werewolf to me.
October 24, 1998
We are getting closer and closer to exams now. Please excuse me if I am less coherent today; I have been studying all day. In anatomy, we just finished up head and neck. We dissected the tongue, orbit (eye), nose, and infratemporal regions. There is a lot more stuff going on in the nose than I realized. For instance, there is this slit on the inferior nasal meatus (bottom part of nose) called the nasolacrimal duct. It connects your nose to your lacrimal (tear) gland. That is why your nose runs when you cry!
October 10, 1998
What a week it has been! Anatomy lab has taken a turn towards the bizarre. Wednesday, we sawed the cap of the skull off and took out Carl's brain. The brain is covered in a very tough layer called the dura mater. It reminds me of the casing of a lima bean but tougher. The next layer is a thin filmy layer called the arachnoid layer. It is in the subarachnoid space that the cerebral spinal fluid resides. The last layer of the brain covering is the pia mater. You can't really see that. Friday, we bissected his whole head down to the root of his neck. That's right, we actually sawed his head in half. It looks just like the pictures from high school that they use to demonstrate the path of the food through the esophagus. I let my lab partners do the sawing. Right now, we are trying to learn the cranial nerves. There are twelve of them, and they are really complex. In Biochemistry, we are moving so fast! We have 9 hours of lecture every week. If you blink, you can find yourself several sections behind.
September 25, 1998
I cannot believe it has been over a month since my last entry. Medical school is extremely demanding. I have so much to tell you though! We dissected Carl's (we named our cadaver Carl) thorax (chest), and boy, did we find cancer. It was everywhere. His cancer was listed on the assignment sheet as renal cancer, but this cancer obviously metastasized (spread). His cancer was all throughout his thorax wall and left lung. The largest mass was larger than a softball. Carl was a big guy, so before we only saw a small (comparatively to what we found later) bump on his back. There were also smaller growths around his rib cage area. I believe it's safe to say that most of the tissue on the left side of his chest was predominately cancer. Carl's cancer was a light, peachy, fleshy color and fibrous in appearance. When you press into a mass it has the feel of pressing into a hard rubber ball. I was surprised at the extent and invasiveness of the growth. We learned that cancer is when the cell loses control of one or more of these processes:1. cell growth
Cancer is when the body turns on itself. It easy to give cancer a personality, like it was the enemy or a parasite. It's hard to believe that it's the person's own cells gone mad.
2. cell differentiation
3. cell adhesion
4. cell death
LUNG
In the thorax, we studied the lungs and the heart. We actually took them out of the cavity. A person who smokes has a very different lung than a nonsmoker's lung. Their lungs are actually covered in black spots. It looks like soot. A smoker's lung also feels less spongy. The whole lung is darkened and for the most part black. A nonsmoker's lung is pink in color. The cells in a smoker's lung actually change shape/type. It is called metaplasia. Normal pseudostratified ciliated columnar epithelium(fat, rectangular cells with little arms swinging back and forth) of the bronchi will actually transform into stratified squamous epithelium (flat skinny cells with no arms). The lungs are larger than I thought. When you take them out of the thorax the chest is empty! All that is left is the heart and two big holes.
HEART
We also took out the heart.
TIP: One way to get your bearings when looking at a heart is to put your finger in the vena cava and hold it in front of you like it was your heart. In this manner you can quickly tell right from left and top from bottom. Last week it struck me how odd it is that I have held a half a dozen human hearts in my hands. The heart is really interesting. The superior two compartments are called atria and the inferior two are ventricles. Their internal walls are mostly bumpy. In the atria the bumps are called pectinate muscles and in the ventricles they are called trabeculae carneae. There is also this fibrous web-like stuff called chordae tendineae that connects the valves to little rod like muscles called papillary muscles. It is really pretty wild looking. The inside of the heart was more crowded than I thought. There are a lot of structures in there!
SPINAL CORD
Lumbar vertebra have these little processes on them that some perverted anatomist thought looked like breasts. These structures are called mamillary processes. I don't see the resemblance, but hey it's in the text books!
The spinal cord is really neat looking. It's a white cord that stops in the vicinity of the L1 - L2 vertebra. The inferior part of the body's nerves come off at the end in a group of nerves called the cauda equina. It was named this because it looks like a horse's tail (this one really looks like its name). I also found the space that contains the cerebrospinal fluid (subarachnoid space) and the epidural space.
Slipped disk: When the gel-like center of the cord called the nucleus pulposus oozes out of its container the annulus fibrosus. The nucleus pulposus compresses the spinal nerve root. This usually occurs posterior and laterally where the annulus fibrosus is not reinforced by the posterior longitudinal ligament.
Oh, lets see, what else do I want to write? We have learned more stuff in the last four weeks than I am used to doing in a whole semester. In biochemistry we learned how your body takes what you eat and turns it into energy. The energy trapped in the chemical bonds of glucose (sugar) is harnessed to push hydrogen across the membrane of the mitochondria to create a gradient. When the hydrogen is let back across the membrane a protein makes these little energy bonds called ATP. It's just like how a waterfall is used to make energy. The hydrogen is the water and the membrane in the mitochondria is the dam. Many things in the body that are microscopic and macroscopic resemble man-made machines. Is it a coinicidence? When they discovered dams and waterfalls to make energy, I doubt they knew what a mitochondrion was!
August 22, 1998
TIP: Double gloving will greatly decrease the probability of cadaver smell staying on my hands. My cadaver is a 45 year-old white male who passed away last January. He had renal cancer that metastasized (spread through out his body). We (my lab partners and I) think we found a tumor while we were dissecting his back. It was a bulge in his back the size of my fist, and it was as hard as a rock. We will further investigate it later in the semester. People who donate their bodies to the medical school are forward thinking, kind-hearted individuals who usually are terminally ill. It makes you think abour your own mortality.
August 21, 1998
The deltopectoral triangle is the home of the cephalic vein. One of the groups in my lab found breast implants on their cadaver as they were dissecting the chest. It was weird seeing and feeling man-made material inside human tissue.
August 19, 1998
The anatomy lab smells bad. Adipose tissue (fat) is bright yellow and greasy like oil. It looks like butter.
August 17, 1998
Anatomy comes from the word anatome. Ana=up and tome = cutting.
August 10, 1998
TIP: Make sure that the lender that you choose for your student loan only capitalizes the interest at the time of repayment. Some banks will add the interest to your principal up to 4 times a year. This means that you pay interest on interest! Not good.
