Andrew’s Demented Summer—Literally and Figuratively

Medical students only get one real summer vacation in the course of their education: the break between years 1 and 2. Hence, this is my one and only official summer vacation (of any meaningful length) for the next four years.

Oh, but there’s a catch. I’m actually working through the vast majority of the summer, principally because residency programs frown upon excessively leisurely medical professionals-to-be. In order to secure a better residency, most medical students therefore use this “break” as an opportunity to engage in salient activities pursuant to their future careers. These include finding clinical internships, working at a medically-oriented camp for underprivileged high school students, heading overseas to provide medical care in poor rural areas or becoming involved in medical research programs. Given my history of neuroscience research in affective disorders and schizophrenia, I decided upon the latter.

I received a Roessler Grant to conduct clinical research under Dr. Doug Scharre, head of the Department of Cognitive Neurology here at OSU. He developed a powerful, useful clinical screening test for mild cognitive impairment and early dementia called SAGE (Self-Administered Gerocognitive Exam). I can’t describe my work in too much detail since my research hasn’t been published yet, but essentially I am establishing normative data and performing statistical comparisons between SAGE and MMSE (Mini Mental Status Exam) scores in order to implement SAGE as a community-based screening tool.

So, what is dementia anyway, and why is a screening tool important? Dementia is an umbrella term for brain disorders that lead to persistent loss of intellectual abilities in memory, language, personality/emotion, visuospatial ability and/or cognition. Alzheimer’s Disease represents about half of all dementias, the pathophysiology of which involves accumulations of two kinds of maladaptive proteins in the brain: extracellular aggregations of an abnormally-folded protein called beta-amyloid, and intracellular (within the neuron) clumps of hyperphosphorylated tau protein. Other causes of dementia can be vascular in nature, toxic or metabolically-induced, related to depression, hydrocephalic, involve Lewy-bodies (as in Parkinson’s) or manifest from varieties of cortical degeneration.

Mild Cognitive Impairment (MCI) represents a transition state between cognitive decline associated with normal aging and dementias. There are potential benefits for the early recognition of MCI given that treatment in the beginning stages may improve the course of the disease. Many barriers prevent the detection of the early stages, such as poor insight by the patient and subtleties in cognitive impairment that are often overlooked during routine examinations. Although several highly specific and sensitive cognitive screening tests exist, they are often poorly reimbursed, time-intensive and cumbersome for healthcare personnel resources. SAGE was developed to combat these hurdles by serving as a sensitive, inexpensive, rapid and easily administered screening tool for MCI and early dementia.

70% of my job involves various forms of data entry and analysis, and the remainder includes administering SAGE in community settings and shadowing Dr. Scharre in order to become familiar with dementias in a clinical setting. Observing demented patients and witnessing Dr. Scharre’s interaction and examination is very illuminating. For instance, patients with MCI seem perfectly normal until clinical cognitive tests reveal subtle underlying deficits. As an example, an individual might give “concrete” answers to questions rather than “abstract” ones: when asked how a train and bicycle are alike they respond that they both have wheels (they are both transportation devices); or when asked how a tulip is like a rose, they note that they both have petals (the abstract answer is that they are both flowers). Probably the most common manifestation of MCI are memory impairments, but I think this subtle deterioration from abstract to concrete thought processes is the most interesting.

I took a week off from this research in order to have a “real” vacation over the 4th of July. Unfortunately, the bulk of the time spent in Maryland visiting friends and family occurred during the worst heatwave since 2006. I was hoping to get a tan, but I couldn’t tolerate even 5 minutes in the sun lest my skin fry like bacon and my blood turn to gas. I’ve resigned to staying pasty for the summer which, I suppose, is better in the long-run given my genetic predisposition toward skin cancer. Nevertheless, it was great to see the fam’ and visit with friends; I’m already wishing I were back there again. Minus the hot/humid weather and egregious traffic, it’s bliss.

I’m trying to squeeze as much leisure from this summer as I can despite my research obligations. I just finished Carl Sagan’s outstanding book, “Demon Haunted World,” and next I will read a book about Henrietta Lacks (thanks, Aunty!) and “Surely You're Joking, Mr. Feynman!” (thanks, Vania!). I’ve also found new television obsessions, including “It’s Always Sunny in Philadelphia,” “Modern Family,” “Work of Art,” and soon I will hook myself on “House” and “Six Feet Under.” There’s a month left before school starts, so I better get crackin’. I figure that if I O/D on TV now, I won’t miss it so much when I’m drowning in schoolwork. Finally, while I’m on the topic of entertainment, I’ll take this time to recommend what I believe are the two best films of the summer: “Toy Story 3” and “Inception.” If you haven’t seen them, get your ass to the theater.

Spinal Taps and Retinal Defects

As you may recall, we have “preceptorships” for which we are assigned to a community physician to shadow and/or assist once a month. Most students were assigned to internal medicine, family medicine, PCPs, cancer docs and the like—but I was assigned to an emergency medicine pediatrician. You may also recall my trepidation given my a priori disinterest—nay, aversion—to both pediatrics and emergency medicine. Yet my experience thus far has demonstrated that I am prone to misjudge my own interests. Pediatric emergency medicine is… amazing. Allow me to describe (while doing my best not to violate HIPAA) the coolest afternoon I’ve had all year.

[Note: patient demographics have been altered to protect privacy]

The fun started the second I walked into the ER. I arrived precisely on time.

“Good afternoon, as of… now!” I said to my preceptor physician.

She pointed to two large monitors behind me. “Andrew, look at those CT scans. What do you see?”

Even if I weren’t in the throes of the Neuroscience block I would have known exactly what I was seeing, because it was unmistakable.

“I see… a brain herniating through a skull with multiple fractures. How…”

“A car accident,” she said. “The poor kid won’t survive.”

What a way to start the afternoon. Soon after, we were standing at the computer while she discussed patients with one of the residents. Afterward, she started to scan the patient list to determine who to see next.

“Room 30, a 7 year-old boy has a foreign body. I want you to take a history.”

“Wait… what? Me?” I thought at first she was talking to the resident.

“Yes, you. I want you to ascertain the chief complaint and take a full history and report back to me.”

“Uhh… well, what’s the foreign body?” I asked, stunned.

She smiled, “That’s for you to find out. Have fun!”

I had never taken a history from a real patient before—just standardized ones (actors, really). However, my CAPS class trained me well and I gathered all the information I needed. A CT scan later confirmed that he fell on a piece of glass two weeks ago and it had recently become infected.

Amidst the myriad other things that occurred, I witnessed three spinal taps, two of which were performed on infants. In all three cases, viral meningitis was suspected pending the results of the CSF (cerebrospinal fluid) analysis. In order to perform the spinal tap on the 9 y/o girl, she had to be kept sedated with propofol so she wouldn’t jerk around too much when her spine was punctured. Yes, propofol—the drug on which Michael Jackson overdosed. It was a milky-white fluid pushed IV throughout the course of the lumbar puncture because it has very acute barbiturate effects. The girl regained consciousness almost immediately after the drug infusion was stopped. Why Jackson’s “doctor” was using it to help him sleep is beyond me.

Following a very successful Neuroscience 1 exam on Friday, I had an awesome weekend. It started that evening at the Olive Garden with Garrett (that is, after we drove to another location upon discovering that the one to which Garrett’s GPS directed us was boarded-up) and watching Boondock Saints before bed.

On Saturday a bunch of us went downtown to The Big Bang, a dueling piano bar. We stayed half an hour longer than anticipated because it was more fun than any of us imagined. I was particularly unenthused since I’m not a big pop-music person (somehow I doubted they would perform classical music), but once again I was wrong to pre-judge. I was at least familiar with most songs, and sang along to nearly half of them. Most of the fun and excitement results from the personalities of the performers. I think we laughed more than we sang…

Afterward we headed to a wine and cheese party hosted by med students, where I proceeded to over-sample different kinds of wine. Well, first we had to drive back downtown because Garrett forgot to sign his card out at the piano bar. You see, like me he’s scatterbrained--but much worse. I’ve lost track of the number of times he’s left important things at my house and other places (phone, keys, etc). The extent to which it’s endearing outweighs the fatigue on my ocular muscles from the exhaustive eye-rolling.

Sunday was another exciting day. After recovering from the wine, a bunch of us went to see Sarah in RENT, performed by the Emerald City Players. It was entertaining, except for a few very pitchy singers (not Sarah, of course). Then we celebrated the purchase of a new grill by hosting a BBQ at our place (officially called “OMGWTFBBQ!”). We had 20 or 25 people over, and lots of food. Good times were had.

Finally, I discovered something interesting about myself at my eye exam today. Apparently, I have a small hole in the upper corner of my left retina. They told me there’s nothing about which to be immediately concerned, but they want me back in 6 months to see if there’s any change. In the meantime, I’m to be on the lookout for any flashes of light or other bogies out of the corner of my eye. Worst case scenario? My retina will become detached. Is this likely? Fortunately, no. If the hole were a small tear there would be greater cause for concern, but unless I suffer brutal trauma to the eye it’s unlikely to become exacerbated. Normally they tell patients about a quarter of what they told me regarding this anatomical flaw, but they said since I’m a medical student I could probably handle fuller detail. I appreciate that. On the other hand, as a medical student I’m already a hypochondriac and overly concerned with slight medical maladies.

In short, I’m not terribly worried about this slight retinal defect. I am worried, however, that I won’t be able to read my music at band rehearsal tonight because my pupils are still super dilated…

A Respite for the Weary

It’s been exactly three months since my last blog post. My bad. I wrote in fits and starts but never completed any of the entries (for instance, I drafted a long-winded entry on cancer during our Neoplasia unit. Perhaps I’ll finish it and upload it post-hoc).

The truth is, school’s momentum has intensified during the past three months. I realize now that the first several months of medical school were simply a warm up—an induction for the rigors to come. Gauging by the counsel of older students, it’s clear that this epoch of our education is the most ruthless of the first two years (aside from board preparation which takes place at the conclusion of Year 2). Much of what follows is a long-winded whine about medical school stress. If you don’t wish to endure that, I suggest scrolling nearer the end (after the ***) :-)

This tyrannical academic chapter is called the “Host-Defense” block, and the low exam averages during this period highlight the duress it precipitates. Aware of this oppressive chapter in our education, the school reminded us at the onset of the block where we can seek psychological support and gave us a stern, ominous warning not to fall behind (because we’d never catch up otherwise).

What is “Host-Defense?” It’s getting hit by a train and then drowned under water beneath the weight of the sunken Titanic. That’s what it feels like, anyway. Really it’s our first in-depth exposure to truly useful, relevant, scientific and clinical medicine. Host1 was concerned with blood-related pathologies (anemias, blood cancers, immunology etc). Host2 encompassed the entire month of February and early March and was concerned primarily with bacterial infections, mycology (fungal infections), autoimmune diseases, lots and lots of pharmacology related to bacteria/fungi, and many other related domains such as sepsis. Host3 begins tomorrow and seems to encompass parasitology, STDs, viruses and other miscellaneous infectious processes. In short, Host-Defense covers what can infect you, how it infects you, how it affects you, and how you can treat it. Real medicine.

So, why’s it so hard? There are two main reasons: the impossibly large and incessant volume of information, and the peri-academic demands placed upon us during this episode.

First, the academic strain: I will try to put this in some perspective. On average, we receive three 1-hour lectures each morning, each of which consists of a powerpoint averaging 45 slides worth of information (although the slide-count can range between 30 and 80). Unless specifically told by the professor, we are responsible for everything on those slides—every last detail. In Host2, there were 40 powerpoint lectures for which we were responsible. In addition to the slides, we are given a course packet, which in Host2 consisted of 329 pages. Some of this is supplementation to the powerpoint content, but we can be held responsible for information found in the course packet which was not specifically addressed in our powerpoint-driven lectures. In essence, it’s a shitload of information.

Since we, as medical students, are better understood as “professional studiers,” this wouldn’t be such a big deal (though still formidably knee-knocking) were it not for the ancillary demands and pressures place upon us. I won’t describe them in detail, since I have done so in previous posts, but I will enumerate them (at least as they apply to me):

1. CAPS class (Clinical Assessment and Problem Solving): Our weekly 3-hour afternoon class that dicates additional assignments for us including:

a. Preceptorships (I will discuss this later in the entry)

b. Senior Partners Program assignments

c. OSCE examinations (clinical skills practicals)

d. Community Projects (for which I volunteer at Goodwill and teach Pilates, give trumpet concerts and conduct nutritional seminars)

2. The deadlines for several extra-academic projects take place during the month of February. The application for summer research scholarships demanded a significant amount of time from many students because of its exhaustive nature. Countless hours are committed to this that would be useful in preparing for the Host2 exam. Additionally, tax forms must be filled out (thanks, dad) so the FAFSA application can be completed by March 1^st. These things become a nuisance when you have over 300 pages of information to commit to memory.

3. Concert Band rehearsals and concerts. These are mostly welcome, but sometimes feel like an impediment. Often during the week of an exam (and in the two weeks leading up to the Host2 exam in particular), I would be extremely and embarrassingly out of shape for rehearsals because I couldn’t spare the time to “put horn to face,” as my dad says. As principal trumpet of the ensemble, I shouldn’t be so inconsistent in my adroitness, but I don’t have the capacity to practice for several hours a day unlike the music majors in the group. I know as lead trumpet I shouldn’t make any excuses; I take comfort knowing that this is the roughest it will get, and that my playing will be more reliable in the future.

4. Living life. I try not to be one of those medical students who studies all day every day much to the detriment of their development as an individual. I try my best to stay abreast of current affairs, stay fit by attending the gym several times a week, have an active social life that doesn’t revolve simply around studying—and I even started dating again. I want desperately both to stay in touch with “reality” and stay well-rounded.

5. Finally, I was very ill at the beginning of the block, and fell behind early. Stuck in bed trying to recover, I didn’t have the wherewithal to study and I was forced to reschedule several events, like my preceptorship.

***

This brings me to the Host2 exam. Kelsey (my splendiferous study buddy) and I worked very hard together (and had a lot of fun, per usual) preparing for this exam. It paid off. Especially considering the daunting nature and infamous reputation of this exam, I’m happy to say I scored far above the average. I hate to brag—I really do—but I worked my ass off during this particularly grueling period (certainly the most demanding of my life thus far, considering the duration of the strain). By the way, it was 110 questions and 2.5 hours long. I’m thrilled to enjoy the first free weekend I’ve had since… perhaps since winter break. And it’s sunny!! It feels as if the universe is smiling at me.

I want to talk briefly about my preceptorship. Firstly, what is it? It’s a hands-on clinical learning experience for which we’re matched with a physician with whom we meet monthly. I was assigned to work with a pediatric emergency department physician. At first I was very anxious; the two fields in which I was almost certain I didn’t want to work were pediatrics and emergency medicine. So, naturally, I got both in one. Then I realized how this could benefit me—it’s good to expose yourself to that which you consider to be most uncomfortable.

After rescheduling (owing to being sick), I worked for 9 hours in the ER of Nationwide Children’s Hospital… and had a blast. I couldn’t believe how much fun it was (aside from seeing some horrifying things). At this time I’m not certain about which I am permitted to write due to HIPAA, but suffice it to say I’m much more interested in pediatrics and emergency medicine than I was before. I also really like my preceptor. She’s an exceptional physician—great with kids, a fantastic teacher, and she asked me excellent questions (I was stunned to realize how much I knew. I guess medical school is working).

I’ll ask around to see how much detail I can describe concerning my preceptorship experiences (my next one is scheduled for this Friday), so until then I’ll hold off.

Now for something cool. I want to share one of the grossest pictures we came across in Host2. Unfortunately, I cannot reproduce the image here in full due to copyright infringement, so I had to find a weblink for it. However, it’s low resolution and has an annoying graphic on it. Hopefully you’ll get the gist.

This is mucopurulent cervicitis (pus-filled, infected cervix) colonized with Chlamydia trachomatis. This is why you should have protected sex, ideally not with strangers. Chlamydia is the most common STD, beating out both gonorrhea and syphilis.