Bugs and More

For the past three weeks, and for the next three as well, I have been and will continue to learn all about infectious diseases. Viruses, bacteria, parasites, fungi. You name it, we're probably learning about it. While we are currently about halfway through the process, we've only just begun the bulk of the material (bacteria) yet have completely finished viruses.

Don't get me wrong: viruses are very interesting. At the beginning of ID I thought they were much more impressive than bacteria could be. I mean, come on, bacteria can at least understandably be viewed as tangible organisms. We can see them move and divide. They are cells just like us. They have a cell wall, sure, but we can see the connection. Viruses? They're pretty much just little grenades with nucleic acid, bits of DNA and RNA covered in a protein capsid. How can we rationalize that? Pretty creepy little things.

                                    Viruses: addressed "to whom it may concern." 

Imagine my shock when we began discussing something that put viruses to shame. Made viruses into pocket-watches while they become the sundial. Of what do I speak? Prions.  They are nothing more than little chunks of protein that infect cells and then screw things up. By "screw things up" I mean "get into your brain and then create tiny holes." They're the culprit behind disease like Kuru and Mad-Cow. They make no sense. Humans, animals, plants, etc? Gobs of cells all chocked full of organelles and DNA striving to make a living in life. Bacteria? Little cuties we can't help but feel sorry for. It's like they're trying to be us but just can't ever quite get there (don't feel too bad for them: Exhibit A).  Viruses? Jerks that just keep trying to take over; the ants at our proverbial picnic.

But Prions? They just want to watch the world burn.

                                       Namely because they would survive it. 

What do I mean by this? In 1986, people in the UK burned over 4 million cows who might have been infected with BSE (Mad cow). And I mean torched. We're talking over 1000F heat. They then buried the ashes underground in a concrete container until 1998. TWELVE YEARS. At that point they opened the container and found the prions still smiling right back, waiting to continue their rampage of destruction. Wicked, eh?

So should we be worried? Pouring buckets of cash into prion research so that we don't all have chunks of protein infecting our brain?!

Not really. Turns out the major way to get a prion disease is via ingestion of infected tissue, also known as eating brains. This is why Kuru has only ever been historically found among people of the Fore tribe in Papau New Guinea (who engaged in cannibalism) and BSE was spreading because of the use of animal feed made up of dead-and-processed-other-animals. I'm going to spare you all the lovely photo of such a mental image that was included in our lecture. (Edit: to clarify, the most prevalent form of prion disease in humans is CJD which comes from ingesting infected beef, which likely themselves had infected food from animal products. Details.)

Oh, medical school.


Until next time.

Not Quite The Beginning - Part 2

Carter grimaced when he saw the number. Pushing the side button on his phone, the call disappeared from view but remained in his mind. Could it have really been 3 years? Leaves crunched under his feet as Carter cut through the small park toward his dreary apartment building. The wind nipped at his exposed skin and forewarned the coming cold front and autumn storm. Trash littered the worn stoop of the old brick building before him. Dropping his shoulder to push open the heavy door, Carter doubted himself. Did you really think he wouldn't show up? Come calling as soon as he was out? You know him and you know he'll never change. But can't I change, he thought, arguing with himself.

After he had climbed the four flights to his one bedroom apartment and set down his bag, Carter's phone vibrated against his thigh. The accompanying tinny ringtone stopped when he pushed the talk button.

"Carter Hamilton, it's about time you picked up," Jackson's familiar voice said. "You really gonna leave an old pal like me hanging?"

"Jackson," Carter said, "how are you doing?"

"What do you mean, 'How am I doing'? How would you be after breathing free air for the first time in 3 years? I'm fucking fantastic. Glad to be out of that concrete shithole."

"I can imagine," Carter replied. Specks of dust drifted through the air in front of him, catching the evening light.

"Well now, no you can't, can you?" Jackson spat. "You weren't caught. Weren't even arrested or talked to, if I remember correctly," he added. Carter stopped pacing. Seconds ticked by. "But, let's not rehash the past. A new leaf and all that bullshit." Carter heard the squelch of a train through the phone.

"What can I do for you?" he asked. Unease twisted through his stomach, as he waited for the words he knew would come.

"I've got a job," Jackson replied. "And I could use your services." Carter felt bile seep into his throat.

"Jackson," Carter began, "I don't know if I ca-"

"You shut it. Stop right there," Jackson interrupted. "I don't want to hear a thing. Not one word. I knew you'd go soft with me gone. You never had a damn backbone." Carter closed his eyes and willed himself to say something, anything. "I don't know what you don't understand. You're the alarm guy. That's it. You deal with all the electronic crap, cutting your wires, and I handle everything else. Stealing ain't exactly a complex science."

"You don't understa-" Carter stuttered.

"No," He said. "Just meet me in an hour at the old diner on 23rd. I could use some real food." And with that, Carter heard the line go dead.

Not Quite The Beginning

As they ran, the alarm slowly faded behind them. This wasn't how it was supposed to happen, Carter thought. He and Jackson darted through the alley, their footfalls heavy and loud on the uneven concrete. No one was supposed to be there. No one was supposed to get hurt. Rounding the corner, Carter saw the flashing lights of police cars. He felt grief well inside him, the ocean of inevitability pulling him into the undertow. Jackson, struggling to keep up, gained ground as Carter stepped from the alley and abruptly stopped at the edge of the road. The wail of the police sirens grew as it bounced from the empty buildings. 

The first of the black and white cars whipped around the corner. Knocking Carter to the side as he ran past, Jackson darted into the street. Carter felt the world slow as the cruiser's brakes locked into a skid. The bumper clipped Jackson's legs at the knee and bounced his body off the hood. He flew forward into the air. His face hit the pavement with a wet slap. The bones in his neck cracked with a hollow pop. Carter stared, aghast.

"Sir!" The policeman yelled, as he jumped from the car. "Sir, are you alright?"

Blood seeped into the cracked cement. Carter looked up and saw police cars surrounding the area. He looked to the growing crowd of policemen.

"What happened?" a patrolman asked.

"Is that the suspect?" another said, motioning to Jackson's lifeless body. The officers looked to Carter. Their faces wore concern beneath the flashing red and blue lights. The sirens had ceased, giving way to disturbing silence.

"Sir, what did you see? Do you know this man?" the original officer asked. Carter looked to them in disbelief. He realized how the scene must look to the policemen. They don't know what happened, he thought. Jackson's dead eyes looked through him from the street. Carter felt a heavy weight creep into his stomach. The tar brewing inside grew thicker as he paused, choking to keep it down.

Taking a shuddered breath, Carter began to speak.

A Severe Lack of Free Time

A Very Talented Man

Last Saturday, nary a week ago, I attended the kicking wedding reception of my two friends (these ones: here and here). The beer flowed tastily, if not entirely clearly, from the tap. The speakers thumped with a good mix of dance music and people were out tearing up the dance floor. For those of you who don't know (which I don't imagine to be many), I occasionally tap my foot to music. Or...well...how else could I put it?

If there's a party with good music, I will dance like hell all night.

I imagine this to be an accurate representation of both myself dancing and others' reactions. I call those others "losers who should be dancing."

This has never been a problem before. I wouldn't even go so far as to call it a problem in this circumstance, it just had... unforeseen consequences. Literally not seen.

Let me begin by stating my new, and now passionate, belief: drinks should be restricted from the dance floor. Be honest. Have you ever been able to really dance well holding a drink? You're always worried about someone bumping into it or you spilling it on yourself or someone else. You may just be worried about losing any of your precious drink, not even on yourself or others. And forget about looking good while dancing and holding a drink. One arm either becomes a magic stabilizer and awkwardly doesn't move while the rest of your body shakes, or you opt for the up-in-the-air, my-drink-is-safer-up-high hold. Either way, it just doesn't work out. The solution? Ban drinks from the dance floor. It would make everyone less worried and look cooler.

Such a ban would also prevent awkward, dance-ending injuries that freakishly happen out of nowhere and could obviously happen to anyone not just a guy who was GIVING it on the dance floor and has genetically lax knee ligaments.

Obviously.

It's true. I'm such a talented man that God Dance and God Awesomeness must have taken note and said, "Whoa. That is too much dance for a mere mortal. We must stop it. Brother God Misfortune: shut him down." And down he shut me. With a perfect storm of events, my left foot at once betrayed me, jutting quickly to the side of my body riding that frictionless train of spilled beer. Mere nanoseconds later, at the moment when my foot jumped from the beer train and landed at a standstill on dry floor, my body was jostled- unmaliciously- by a fellow dancer. This led Left Knee, previously one of my most dependable soldiers on the battlefield of dance, to be attacked on simultaneously on two fronts. Painfully, he exclaimed,"FFFUUUUUUU[[CENSORED]]!" and hit the ground.

My left knee popped, buckled, and I went down. Having had a past experience of dislocating my right patella and it being surgically repaired, I was worried and cautious. I hopped up and was able to get off the dance floor and onto a nearby bench. The knee felt really tender and sore, but fortunately did not have any sharp or continuous pain. This took any kind of a bone break off the table for my differential diagnosis, but ratcheted a ligament tear to the top of the worry list. Being the stupid man that I am, I tried to "walk it off" and do a few laps around the place. I was able to walk,which was definitely a plus, but could tell it was going to be out of commission for a while. My caring but concerned wife and I were able to make a quiet departure from the reception, grab some NSAIDs and ice from a friend in town, and make our way home. Over the next few days I made a doctors appointment and self-prescribed the RICE protocol and ibuprofen. My knee seemed to improve and I became mildly confident it was a sprain with no tears. Yesterday, the real doctor concurred with my diagnosis. He recommended I take it easy for a week and then slowly work back to normal use and exercise. Also advised was this bold fashion statement.

I fully expect it to become the hot and wild new trend of the upcoming fall fashion season. I hear it's already huge in Europe.

Pretty strange events, all things considered. My advice? Keep dancing like hell. If you don't already, give such dancing a go the next time you have the chance. It's just too damn fun not to.

Until next time.

Not Quite All-Star Material

I've been in a bit of a dry spell with the blog. Who knows why we've had this high pressure system for so long, but I've decided to go ahead and rain some words down for y'all.
(Y'all? I don't know either. Just go with it.)

So, in honor of my trying to return to form, I'm going to tell you a little story.

As stated previously, I'm currently working in pediatrics. It's been a really good experience thus far, and there have been some really interesting cases and children. This seems to be a general trend in medicine. As much as any other profession, it offers wonderful examples that solidify the simple truth that people do interesting things (to say the least).

[Exhibit A: The man who was ruthless attacked by a pasta noodle.]

When kids are added into this mix the results can truly take off. I just imagine all the things adults are capable of and add in the non-existent social rules that govern children. They will say and do just about anything.

Picture yourself as a young medical student. You're in clinic and seeing a hilariously talkative 4 year old Boy who's at the doctor for throwing up. After checking things out with Mom and Boy you go present the case to Doctor. (Boy, by the way, is essentially healthy. The source of his emesis? Eating too many bed time snacks. No joke.) Upon returning to the room with Doctor in tow, Doc and Mom proceed to talk some things out. You, as Medical Student, are sitting quietly on the stool and observing. At this point, Boy is quietly sitting on the footstool and intently looking back and forth between You and Doctor. Boy then slides his stool up to you, right in your grill (medical term). He leans in -leading you to lean in, as if you're sharing a secret- and, looking at Doctor, asks:

Boy: Is tha'chya Momma or ya Gran Momma?

You: *Blank Stare* (trying not to laugh)

You: What?

Boy (much more intently, while motioning with his head): Is tha'chya Momma or ya Gran Momma?

You: What? Neither! That's the doctor!

If you can come up with a fitting reply to that, I welcome it for the future. Another scene from the same visit:
"What do you normally eat for a bedtime snack?" the Doctor asks.

Boy pauses, as if this is some kind of a trick. He boldly replies,

"Oatmeal!"

Her brow furrows in disbelief.

"Oatmeal?" she says.
A grin slowly creeps across the boy's face.

"Cookies!" he quickly adds.

This was obviously a very entertaining visit. Occasionally, however, the excitement comes not from the patient but the doctor. Or, in this case, the medical student.

I suppose I should just come out and say it.

I hit a kid in the face.

And made him cry.

I know what you're thinking:

But that is not the case (kind of). Let me explain. Kids are fussy. It's a fact of life. So sick children are especially fussy (by "children" I more accurately mean this 11 month old.) I was working with another medical student who was trying to listen to this child's lungs. The child was unhappy and crying. Let me tell you, it's hard to hear breath sounds when they're being dominated by loud wailing. To help with this, I pulled my ID badge (clipped to my white coat on a retractable...badge...clip) and was loosely holding it in front of said screaming child to function as a distraction.
This is what I'm talking about. Although mine isn't FBI. Sadly.

It worked. Seriously. It often does. The kid starts playing with the badge, and boom, no more crying. Unfortunately, the aforementioned retractable badge clip felt that now was the most opportune time to become UNclipped from my white coat. This resulted in it rocketing from my hand and hitting the first thing in its path...

...the kid's face.

A reenactment of what may have happened.

I know! I know! I'm a terrible person. Needless to say, I went ahead and left the room at that moment. The boy was unhappy and me being within sight of him wasn't going to help. In my defense, however, it was the card and not the heavy retractable part that hit him. When it was all said and done he was alright and not worse for wear.

Kid's are resilient, right? Especially in the facial...region.

Until next time.

Not The Most Diligent

Okay, I may or may not have been a wildly ineffectively blogger for the past few weeks.

I understand this. Let's all just move past it.

We left off at the beginning of the Cardiopulmonary module. The first half the module, Cardio, is now over and I'm pleased to report it was a rousing success. While I now know more than I ever wanted to about the electrophysiology of the heart, it has been interesting and a good module. We've learned much more doctor-ly things such as how to read ECGs (there actually is information in those squiggly lines) and listen to the various heart sounds (<--INTERACTIVE!). To me, learning about heart defects has been one of the more interesting subjects. While I won't go into big hairy details, one aspect is too cool not to share. In general, I think we can all agree that having a heart defect would be an unfortunate thing. That is, unless you've got more than one defect. Sometimes, having a heart defect can actually save your life. More on that later, but first, a bit of background to fully appreciate what's going on here.

Your heart is made up of four chambers (atria and ventricles), separated by four valves, and can be divided into left and right halves. The ventricles are the lower chambers of the heart and are the real workhorses. The atria (plural for atrium) function to kind of "prime" the ventricles and keep the blood flowing.

Blood that has been in your body (deoxygenated) flows into the right atrium. From here it passes through the tricuspid valve and into the right ventricle. The right ventricle pumps blood through the pulmonic valve and into the pulmonary artery where it goes to the lungs to gain oxygen. Once the blood has oxygen, it flows from the lungs and into the left atrium. From here, the blood passes through the mitral valve (named for a bishop's mitre) and into the left ventricle. The left ventricle pumps blood through the aortic valve and into your aorta where it goes to your entire body and provides that much needed oxygen.

Having a hole in your heart that changes this flow of oxygenated/deoxygenated blood constitutes a fairly large number of heart defects and many of them either close on their own or can be fixed. (In fact, when you're growing in the womb, it's normal and necessary to have one so your blood bypasses the lungs.) But I digress.

One major heart problem is called Transposition of the Great Vessels (technically dextro-TotGV, but we're simplifying here). Because of a problem during development, a person's pulmonary artery and aorta are switched. Aside from this sounding scary (which it is), it prevents blood from undergoing its normal exchange of oxygen. Oxygen-rich blood simply cycles from the lungs, through the left side of the heart, and back into the lungs. Oxygen-depleted blood from the body enters the right side of the heart and is pumped into the aorta and back in to the body. Having this defect on its own is, as they say in school, "incompatible with life." (How's that for cold medical talk, eh?)

"Bad News"---^

Now you may be asking yourself (if you're still reading), Okay, Matthew, where does the coolness of this all come in? Cause right now, you're just talking about fatal heart defects.

I understand, dear reader(s). The cool part about this is that if a person has transposition of the great vessels AND another hole-in-the-heart defect (such as Patent Ductus Arteriosus or Atrial Septal Defect), the second defect allows just enough oxygen to intermingle and flow what is normally the wrong way that the person stays alive. When this dual defect is coupled with the (hopefully) astute actions of the medical team delivering the baby, the doctors are able to recognize what's going on, rush the baby into surgery and swap the vessels around to where they are supposed to be.

That's right, crazy-emergency-heart-surgery-on-a-baby-that-has-a-success-rate-of-OVER 90%. Medicine FTW! (FTW= For the Win)

Until next time. (Which will be much sooner- I know, I know.)

Quite Interesting

While I shy away from directly copying direct work (and instead prefer to link), I repost this from another (who was herself doing so), because I think it's quite interesting and raises some good questions.

Washington, DC Metro Station on a cold January morning in 2007. The man with a violin played six Bach pieces for about 45 minutes. During that time approximately. 2 thousand people went through the station, most of them on their way to work. After 3 minutes a middle aged man noticed there was a musician playing. He slowed his pace and stopped for a few seconds and then hurried to meet his schedule.

4 minutes later:

The violinist received his first dollar: a woman threw the money in the hat and, without stopping, continued to walk.

6 minutes:

A young man leaned against the wall to listen to him, then looked at his watch and started to walk again.

10 minutes:

A 3-year old boy stopped but his mother tugged him along hurriedly. The kid stopped to look at the violinist again, but the mother pushed hard and the child continued to walk, turning his head all the time. This action was repeated by several other children. Every parent, without exception, forced their children to move on quickly.

45 minutes:

The musician played continuously. Only 6 people stopped and listened for a short while. About 20 gave money but continued to walk at their normal pace. The man collected a total of $32.

1 hour:

He finished playing and silence took over. No one noticed. No one applauded, nor was there any recognition.

No one knew this, but the violinist was Joshua Bell, one of the greatest musicians in the world. He played one of the most intricate pieces ever written, with a violin worth $3.5 million dollars. Two days before Joshua Bell sold out a theater in Boston where the seats averaged $100.

This is a true story. Joshua Bell playing incognito in the metro station was organized by the Washington Post as part of a social experiment about perception, taste and people’s priorities.

The questions raised:

*In a common place environment at an inappropriate hour, do we perceive beauty?

*Do we stop to appreciate it?

*Do we recognize talent in an unexpected context?

One possible conclusion reached from this experiment could be this:

If we do not have a moment to stop and listen to one of the best musicians in the world, playing some of the finest music ever written, with one of the most beautiful instruments ever made.

How many other things are we missing?

The source article from the Post can be found here and is worth a read. It includes a video.

Until next time.

Wait...What?!

Being paired with a local physician (preceptor) that we visit at least once a module makes up one of the clinical aspects of our first two years. It is with these preceptors that we have some of our aforementioned "patient contact." The experience generally lets us get more comfortable pretending to be doctors with being student physicians, but more than anything it helps reaffirm why we're all here. What do I mean by this?

As my preceptor and I sit in the side office of the clinic and he fills out the chart of a patient we just saw, the nurse walks in and hands me (as the real doctor is still busy) the next patient's chart. I glance down to see at what we'll be looking and my eyes go wide with surprise.

The Chief Complaint (i.e. the reason for coming) box reads:

Right Thumb- splinter under nail (noodle).

As one might imagine, I reread that sentence a few times. Curious, I look up at the nurse and she, trying to contain her surprise/amusement/disbelief, explains that he was cleaning some dried pasta from a pan and voila:

Noodle + Under + Thumbnail = Pain.

The real downside of this for the patient (It was great for me. I got to watch and help with something unusual.) is that pasta, being a grain product and rather moist, acts as a pretty poor tenant when leasing sub-cuticle space. After about 10 minutes of Lidocaine shots to numb the area (oddly enough the most painful experience for the guy), half of his nail cut off, and some nimble forceps work by my preceptor, he left likely feeling physically worse but thumbnail-infection/pasta free.

I am certain that while this is the first semi-strange experience in my medical career, it will not be the last. Until next time.