Vile Bile

I knew something was wrong when I saw the green goo, but I significantly underestimated how severe our problem was.

Today in anatomy lab, our task was to cut into the abdomen and explore the structures inside (e.g. mesentery, intestines, stomach, liver, spleen etc.). It sounded so simple. The first few steps involved making a cross-shaped incision in the abdominal wall out through the umbilicus (belly button) and reflecting the layers back to reveal the viscera.

Carefully trying to avoid damaging the underlying omentum, I made my first incisions very superficial. Then, on the third stroke:

“Whoa…”

Green goo. Oozing out of the incision.

“Is that bile? That’s impossible! There’s no way I cut that deep!” Bile is stored in the gall bladder, which is located on the inferior surface of the liver.

The four of us stared at each other with bemused expressions.

We continued to open the peritoneal (abdominal) cavity, becoming increasingly aghast at the deep green soup saturating the intestines and pooling in the crevasses between.

“This doesn’t make any sense. Maybe her gall bladder exploded post-mortem?” one group member suggested.

We called over one of the doctors, who explained that the embalming process sometimes increases the pressure inside the gall bladder, causing it to burst.

I sighed some relief. At least it wasn't my fault.

Noting that our misfortune was par for the course, we continued the dissection resigned to the fact that our internal organs would be dyed green. No big deal, right?

“Wait, what is that thing? It can’t be the omentum. Wait… where is the greater omentum? It should be right here on top!”

Rather than seeing the expected fatty, vascularized extension of peritoneum that covers the intestines, we saw this huge, hard, green (from the bile spill) brick-like thing just under the peritoneum.

After some wild conjecture, we looked at one another with hopeless expressions and called the doctor over once more.

“Whoa,” he said. Glad we weren’t the only ones with that reaction.

He spent a few minutes exploring the cavity, trying to understand what we were seeing. Eventually he reached several conclusions:

1) The huge brick-like object was impacted colon (it must have more than quadrupled in diameter).

2) The omentum had fused to the parietal peritoneum and begun to disintegrate, which is why we didn’t see it.

3) It was a mess.

For whatever reason—perhaps related to metastatic ovarian cancer—Bertha was extremely constipated. Perhaps for the same reason, the omentum tried to contain this growing mass in the abdominal cavity by growing around it to seal it off from the rest of the viscera. We actually learned earlier that day that this is a useful function of the greater omentum: it can form adhesions to adjacent inflamed organs to partition it from the other viscera.

At any rate, what ensued was the most horrific sequence of events I hope to experience in anatomy lab. We had to remove the impacted colon so that we could gain access to the rest of the abdomen and—hopefully—continue with our dissection.

It’s difficult to be sure, because the anatomy was altered so much, but we think the affected portions of colon included the transverse, descending and sigmoid segments (altogether a significant portion of large intestine). The rest of the colon was impacted as well, but not as distended as the more distal regions.

We tied off the most obstructive part of impacted colon with string and used a scalpel to snip it out. Perhaps “snip” is the wrong verb, though. It was about the diameter of a lower leg.

But the knots of the string didn’t do the trick. They slipped off the cut edge. What now?

We milked the feces out of the colon in order to better tie it off.

Yes. I helped to milk several pounds of green, bile-stained feces out of an impacted colon.

Although the experience totally grossed me out (though we all kept our equanimity), I couldn’t help thinking about how much pain the living Bertha suffered. “Excruciating” would surely be an understatement. This sobering notion helped to remind me of the respect we must afford the cadavers. One of the most offensive things we can do is to lose our composure.

(Normal abdomen, courtesy www.NetAnatomy.com)

1st Medical School Exam, and a bonus rant

Elation. Relief. Reinvigoration. I made it through my first exam unscathed, and with a renewed sense of optimism. I performed far better than I imagined in my most optimistic moments, and in hindsight I can see I worried far too much. This whole medical school thing? I think I can do it!

We were given nearly two hours to complete the computer portion of the exam (75 questions). I was surprised how little time it took me to get through—I finished in under an hour, allowing me 2 more hours to study for the practical. I was already in a good mood by that time, because we receive our computer portion scores immediately after we submit the test (I got an A), so there was an instantaneous relief of pressure. I headed to Panera bread, grabbed some coffee and a bagel, and sat down to leaf through my Grant’s Dissector (our lab manual for anatomy dissections).

I was impressed with the practical. The 3 anatomy labs hosted about 60 stations, 50 of which had structures to identify (the other 10 or so were waiting stations that provided an opportunity to relax, check spelling and reconsider answers). We had a minute per station, following-the-leader to the next item when the buzzer went off. 40 cadaveric structures (muscles, tendons, nerves, arteries, veins, ligaments etc) were marked with either “I.D.” or “motor innervation.” The other 10 included things like angiograms, cross sections, bone markings and CT scans. I found both the written and practical portions of the exam to be very fair; I can’t think of any negative criticism. I haven’t received my score for the practical, but I knew ahead of time that I could get 33 wrong and still pass.

I spent most of the weekend relaxing; I haven’t done any work whatsoever. On Friday I finally practiced trumpet and hit the gym, went out with other med students to a bar in the Arena district, and then ate cookies and played games all night. Saturday I saw “Up” (LOVED IT!) at a Dollar Theater (except it was $2, those lying bastards. **shakes fist**) and went out with a couple friends from D.C. who were in town for the OSU v USC game. This morning, Sarah, Mike, Duane and I engorged ourselves with a pancake brunch and watched this hilarious sketch comedy show I Netflixed called “Little Britain USA (I HIGHLY recommend it). Tonight my friend Chris is making me dinner; I hope I’m not still full with pancakes…

Time for a mini-rant. I got a call from our landlord telling us that she received a complaint that our grass is too long, and that we need to mow it by Monday lest she get in trouble with the township. Before I get too angry, I’ll concede that we agreed to mow the grass when we started renting the house, but we’ve been too busy to purchase a mower or pay a neighbor. That is being rectified in an hour thanks to Craigslist. So, fair is fair. That said—

1) Who the hell had the audacity to complain about a lawn that isn’t theirs? I don’t like the color schemes of some of the houses on our block. Should I have the legal right to complain to the city about them? Can I complain to the city about the dog that barks its head off and keeps me up at night?

2) Why should anyone care so much about a lawn in the first place, let alone someone else’s? It’s just grass! Aren’t there more important things to concern yourself with, or is your life really that boring and unfulfilled?

3) Lawns are an abomination anyway. It’s unnatural to have homogenous flora in the first place. That’s why weeds crop up. They’re not invading your lawn; it’s simply nature trying to reestablish equilibrium. This country has an unnatural obsession with lawns. We spend a fortune on fertilizers, weed killers, and we waste water on them during dry spells to keep them green. And hey, if grass isn’t green, that’s OK too! It’s normal. Grass goes dormant when it’s too dry. Find some other metric by which to judge your neighbors. Or, better yet, don’t judge your neighbors.

Alright, now I feel less pissed. I’m gonna go catch up on Project Runway!

Toilets and backpacks

I was sitting on the toilet when it dawned on me how cool knowledge of anatomy can be.

You know how parts of your leg can get numb/tingly/weak when you sit there too long and/or in certain positions or postures? I realized how awesome anatomy is when I discovered that I could name all the nerves and arterial supplies (and consequently their branches and innervations to various muscles) that are being compressed to give me that particular sensation.

For instance, last night I had this thought:

"I must be compressing the common peroneal (fibular) division of my sciatic nerve, which is paired with the common tibial division more deeply (so it's not as compressed), and which branches off (as the common fibular nerve) to wind around the lateral aspect of my knee, after which it splits into the superficial fibular branch supplying the lateral aspect of my leg and the deep fibular branch which supplies the anterior compartment and gives off the lateral sural cutaneous nerve, and that's why I have this sensation along the anterolateral aspect of my leg, but not the posterior compartment because that's innervated by the tibial nerve--the superior portion of which is not compressed in its tibial division of the sciatic nerve--and not the medial or posterior compartments of my thigh because they're innervated by the obturator nerve and tibial division of the sciatic nerve, respectively, and cutaneously by the inferior cluneal nerve."

No joke. That seriously went through my mind.

I also have an extremely heavy backpack, and had a similar thought walking home the other day as it compressed my suprascapular nerve running deep to my transverse scapular ligament.

Maybe there will be question about toilets on the exam tomorrow...

The answer to my question is "no."

It’s appropriate that I ended the title of my previous blog with a question mark (“End of the Maelstrom?”). The answer is no. It was only the eye of the storm. I won’t dive into a full explanation; you can probably guess (e.g. the main contributor is the colossal information load that I’m supposed to assimilate). It’s old news, but the pressure is mounting as the exam (this Friday) no longer looms in the horizon, but terrorizes me like a swiftly advancing tsunami.

The exam will consist of 75 computer-based questions (55 medically-related anatomy; 20 embryology) and 50 practical questions (40 tagged structures on our cadavers, plus 10 from cross sections and medical imaging). The computer-based questions begin at 8am. The practicals are offered to different groups at various times throughout the day. Because I always draw the short straw with such matters, I will be in the first group, which means I have little-to-no time to squeeze extra studying time in beforehand.

I feel moderately confident. I took a practice quiz and practice practical and passed both (meaning I got above 70%); many people failed. They were designed to be a little more difficult than the real exams, too. Still, I feel that the older information is leaking out as I try to stuff more in my head. We’re on the lower limb now, and I’m starting to forget the arterial and nervous roadmaps of the upper extremity. My plan is to spend the rest of today learning this weeks’ lecture material, and all of tomorrow consolidation the entire 4 weeks’ worth of knowledge.

Enough exam-talk, though. We had a potluck at our house this past weekend after playing volleyball for a couple hours. I made lasagna (thanks, mom), Mike brought wings, and Sarah and her visiting boyfriend brought the ingredients to make turkey egg-rolls. Delicious. Much Rockband2 ensued, naturally.

We had our first experience with ultrasound last week. There was a lecture describing the mechanics of the technology, followed by some demonstrations. At the beginning of the lecture, none of the images made sense; it all looked like grayish blobs. Toward the end of the lecture, things were starting to click. By the time we had the opportunity to use ultrasound machines ourselves the next day, I could mostly understand what I was seeing. We imaged the glenohumeral (shoulder) joint, structures in the wrist, and the knee joint.

Last week culminated in a Community Project Fair, during which we rotated around to 60 or so tables for organizations that offer volunteer opportunities to med students. We can volunteer with as many as we’d like, but we are to choose one to serve as a community project to which we will devote a substantial amount of time and energy. There are at least two I’m seriously considering. One involves a mentorship with an elementary school student for which we’d visit the kids at their school once a week (or so) and serve as a positive role model. Another involves counseling physical therapy patients on proper exercise technique, nutrition, answering medical questions etc. There’s also a program that I’m not considering for my project—but in which I plan to participate—called “Walk with a Doc.” All you do is show up at the park on a Saturday morning and spend an hour walking around with elderly individuals. It sounds like a great way to spend an hour of light exercise.

Earlier this week I had my first practical assignment for the clinical skills center as a part of the CAPS course. I was sent into a room with a patient and instructed to use the BATHE method (Background, Affect, Trouble, Handling, Empathy) for developing/refining information acquisition and interpersonal skills. In essence, I introduced myself to a standardized patient (actor) as a first year medical student, washed my hands, and had a heart-to-heart with a woman with knee pain. The point of the exercise was to cull as much information from her (Background) using open-ended questions, eventually delving into second-order effects of her malady (Affect, Trouble, Handling) and empathizing with her. Apparently, she couldn’t use the stair-master due to the pain, for which she was taking Ibuprofen, and which was putting additional strain on her already stressful life (a single-parent divorcee). The entire encounter was video-recorded and I will receive feedback next week.

My goal for the weekend is to construct a more-upbeat post during which I’ll discuss some of the more entertaining things I’ve been doing. Wow. The weekend… I can barely wait.

In the meantime, here’s the cool medical thingy of the day: Caput Medusae. The responsibility veins are to return deoxygenated blood centrally. Superficial veins flow to deep veins, which eventually return the blood to the heart. Sometimes veins get backed-up, and they distend and pool with blood if there’s resistance in the circulation more centrally (that’s how we get varicose veins). In the case of Caput Medusae, the superficial epigastric veins become distended and look like the picture below. It’s named for the snake-like appearance, which resembles Medusa’s hair (which, if you remember your Greek mythology, is composed of snakes). This is most often due to inadequate hepatic portal circulation resulting from diseases like cirrhosis of the liver.

End of the Maelstrom?

The third week is about to commence and I’ve noticed an evolution in my temperament.

Throughout the first week, I was overwhelmed and drowning in anxiety. Midway through the second week I was at peace with the daunting hurricane of information whirling around, threatening to destroy me.

Now? Serenity.

Well, almost. I’ve regained my composure, anyway. Many people prognosticated this, insisting that I’d feel better once I developed a study groove. I think it’s something else, though. I still haven’t determined which study methods/patterns/routines work best just yet. Rather, I think my brain is reconnecting its old synapses from college. For two years it’s been out of practice, forgetting how to remember. Learning is itself a learning curve, and my brain fell off the wagon. It’s that old neuroscience aphorism: use it or lose it.

In short, my brain couldn’t handle the extreme bandwidth of information coming its way. As time goes on, it’s becoming more “fit” and proficient, so the knowledge thrust its way is more easily accommodated. I feel less stupid.

One consequence of all this is that I have more free time for trumpet. I’m still not certain I can allot 4 (or 6?) hours a week for concert band rehearsals, but the audition is on September 23^rd, and I’m nearly in shape already. The audition piece is a cinch, and really plays to my strengths. It’s a lyrical, expressive excerpt from a piece called “A Hymn for the Lost and the Living.” Barring some unforeseen confound, I think I’ll nail it.

On a side note, I have to wonder to what extent I irritate my housemates when I practice. I always ask them beforehand if they mind (and I make sure they’re not studying), but you never know.

In anatomy, we’ve covered the musculoskeletal/integumentary/circulatory/nervous/lymphatic structures of the back, neck, shoulder, arm and hand (yes, in 2 weeks). Every once in a while, an anatomical term will really amuse me. For instance: hold your hand out and extend your thumb back toward you. Do you see that little pocket of skin formed by the tendons between your thumb and your wrist? That’s called the “anatomical snuffbox.” Snuff, as in powdered tobacco that people snorted back in the day (sometimes out of the “anatomical snuffbox,” too).

Week 2 Recap

Update on the cadaver: None of the initial names I suggested panned out. As a joke and last-ditch effort I threw out the name “Bertha,” since it’s a tired, cliché term for any large person. To my chagrin, the rest of the group was very enthusiastic about the idea, so it stuck. Bertha.

Apparently Bertha died at the ripe old age of 83 due to ovarian cancer, Alzheimer’s and COPD (chronic obstructive pulmonary disease). Many of the cadavers—since they’re mostly old folks—died of “failure to thrive.” That seems to be the medical phrase for “old age.”

Anatomy is progressing fairly well despite the huge (no pun intended) obstacle of Bertha’s obesity. We’ve dissected the entire upper and lower back down to the spinal cord, the neck region down to the suboccipital triangle, the pectoral, shoulder, axillary and upper arm regions down to the nerves and blood vessels. The latter two structures are very difficult to dissect on Bertha because they’re buried in layers of adipose globules that render them difficult to find and clean. It takes us nearly twice as long to dissect our body compared to the other groups.

My biggest obstacles regarding the material are the challenging new vocabulary and memorizing the nerve/vessel innervation of each muscle. It’s not uncommon to encounter 100 new words each day, most of which look positively alien (a couple of my favorites are syncitiotrophoblast and rectus capitis posterior major—and yes, spelling counts). Identifying structures on the cadavers can be challenging since they’re… I don’t want to say “mutilated,” but… not pretty. There’s also anatomical variability between different bodies.

I felt extremely overwhelmed and distressed the first week, and spent the vast majority of the weekend studying, thereby minimizing social activities and personal leisure. Although I never quite caught up with the material, I feel more at ease with the pace and volume of information and thus more inclined to be more outgoing again. I feel less stressed and I’ve already made weekend plans. I’m more comfortable feeling behind, and the pressure to master every last detail has waned. Much of the initial anxiety was probably due to the abrupt lifestyle change, and some of the repose stems from solidarity with members of a study group I’ve joined.

I’ve also made plans to shadow a neurologist and scope out the lab of a couple doctors so I can get a jump on summer research plans (if I apply early with a good project, I can obtain a Roessler scholarship). I’ve also signed up to volunteer at the Columbus Free Clinic, and I plan to join the neurology and dermatology interest groups. I’m considering applying for a leadership position in DIVE-IN, a student-run organization that seeks to coordinate shadowing opportunities, grand rounds and specialty panel discussions for medical students.

The title of this blog is called “NeuroTrumpet,” right? I’m trying to stay in shape with trumpet, but at the moment I only get a chance to practice every other day. Since I seem to be adapting to school, I’m optimistic that I’ll be playing every day in a week or two, and be back in shape by mid-September. That’s when the auditions are being held for the symphonic bands at OSU. More on that later.

I’ve decided to leave you with a “cool disease” at the conclusion of each blog, so here’s this week’s. It’s called a sacrococcygeal teratoma. It’s a birth defect that occurs early-on in fetal development and results from inadequate closure of the caudal (tail) end of the primitive streak (a structure that forms in the first few weeks). Since it is derived from pleuripotent stem cells, it contains tissue from all three germ layers. It’s commonly benign, and can be surgically excised.

Anatomy: Day 1

It happened again.

I got the obese cadaver. This happened in 11^th grade Anatomy when we were dissecting cats. It makes the process much more difficult; it takes a lot of time and energy to separate the superficial fascia (fat-containing subcutaneous layer) from the deep fascia and muscle.

On the other hand, the muscles of my cadaver were very large and defined (they must be in order to support the excess body weight), and the fatty tissue held in the moisture very well; the other groups’ cadavers dried out very quickly (although I do wish ours were less juicy—it gets all over the floor and our scrubs).

Since my group has an obese female, I suggested we name her "Merryweather" after the portly blue fairy from Sleeping Beauty. The other group members didn’t seem as enthusiastic about it as I was, so I guess she’s still anonymous for now. Hmm… perhaps "Ganymede," or "Gertrude."

"Marge?" I dunno…

We started with the superficial back. The first task was to make several incisions that essentially circumscribe the back, and then removed strips of the skin to reveal the underlying deep fascia and muscles. It took us about five times longer than other groups due to the body fat, and each strip of skin (approx. 12cm x 30cm) weighed several pounds. At her midsection, I had to cut a good 5 or 6 inches in before I got to the muscle. Each pound of fat, by the way, stores roughly 3,500 calories.

I recalled from 11^th grade that it’s very easy to cut into the muscle when skinning cadavers, so I winced every time one of the group members butchered the muscle. I dissected more conservatively, so the muscle in my quadrant of back was well-preserved (yes, I’m tooting my own horn). The lesson is, it’s best to separate the investing fascia with your fingers rather than the scalpel. It makes for the cleanest separation.

Overall it was a strange experience. Standing around a dead body (that looked like rubber) for 3 hours and inhaling formaldehyde fumes. The weirdest part? Formaldehyde causes one to feel hungry. It was a dissonant thought to feel hungry while staring at the gnarled insides of an obese cadaver.

Maybe Lorraine? Or Agatha? I will meditate on this.