My First Visit to the Morgue

This morning was my first visit to the morgue. Every Wednesday morning at 7:30am the neuropathologist cuts and teaches about all the brains that they are investigating that week. It was actually incredibly clean, bright, and people were altogether in light moods. I'm not sure what I was expecting - zombies?

Today's case was apparently exceptional in the degree of injury:

59 year old man who had died a few days ago after presenting more than a week ago with "confusion, ataxia (feeling off balance), and problems with his vision". He came back in a few days ago to the ER because his daughter could not wake him up. He died later that day. He had a history of alcoholism, liver disease, and diabetes (the last two often stem from the first)

The other pathologist had already done the full body autopsy and found very clear arteries (which apparently is very typical of alcoholics, strange protective effect that can actually be achieved with MUCH LESS alcohol), as well as endocarditis of the mitral valve. Endocarditis is basically inflammation of a heart valve. In this case, it seems to have been caused by an infection of staph aureus which had also entered into his CSF (spinal fluid).

After slicing through the entire brain carefully, the neuropathologist went through the most effected slices. There were several emboli in the brain (emboli = blood clot) probably caused by the heart not working correctly, blood getting backed up, and those clots moving to the brain.

There were emboli in the cerebellum (controls movement), frontal cortex, specifically in the area that adjusts motion as well as the area that controls your eye movement, the temporal lobe (in an area processing what touch means), and in the occipital lobe (which is mostly dedicated to the visual system).

Then we went around and each said one neurological disease process that can be caused, either directly or indirectly, by alcoholism. We got to 38 before I had to run to class, including:

traumatic brain injury from falling (contusions/concussions/hemorrhages),
encephalopathy (increased pressure inside the skull pushing down on the brain),
vitamin deficiencies (B12, and B1; which can cause confusion, delirium, problems with eye movements, problems with the spine),
delirium tremens (tremors or shakes that won't stop),
and hyperglycemia (too much sugar in your blood; which causes all sorts of problems on its own)

This variety of illnesses is why when someone who is an alocoholic comes in in crisis you give them an "alcoholic's cocktail" (different from an alcoholic cocktail) consisting of: a benzodiazepeine (to prevent DTs), thiamine (to proactively treat any B1 aka thiamine deficiency), and glucose (because alcohol prevents your liver from actually being able to use any glucose, and alcoholics are often not eating anything else). This is also known as a "banana bag" because it looks pretty yellow. A clear IV bag should never be given to an alcoholic, because it's missing at least the thiamine!

As we're going around, my fellow first year med student and I are in awe - that all these more advanced students can rattle off these disease processes on cue, but even more so that we understand almost all of what they're saying. The best part about things like this is that as we walked into class this morning to learn about tremors, we paid WAY more attention.


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(completely unrelated)

"a woman is like a tea bag, you cannot tell how strong she is until you see her in hot water" - eleanor roosevelt

Today: Drop Your Pants, Please.

Today at my family practice preceptorship I gave my first (and my second) ever prostate exams on two very kind men. I'm following a wonderful family practice physician who I'll call Dr. Spock because it just fits. So this random Friday afternoon, we were talking with a patient and Dr. Spock says (to the patient) would it be okay if Erica felt your prostate?”, and when the patient says yes, he sort of nods at me and I go stand next to him as he (surreally) directs me on what I’ll be doing.

It's incredible to me that 1) they both agreed, 2) that it actually wasn't that awkward, and 3) that they expected me to be able to tell them very important information about their health afterward.

Mostly I just looked at Dr. Spock and said (very slowly), I don't feel any hard nodules that could be cancer (????????) to which he said, good job. though you will notice that the left lobe is slightly larger than the right; that's something we're monitoring on a bi-annual basis. I nodded (but I really didn't notice anything, all I could think was: whoa, I hope this man is okay with this...). Later, we talked with a man who had just gotten out of jail about his cocaine addiction and how he had become very depressed in jail, but then decided that he wanted to stop his medication because "some things just shouldn't feel okay, doc". After that, we did a complete physical on a two month old baby, including sort of dropping him face forward onto the table, watching to see how he caught himself. I looked at the mother like, really? you're letting me drop your baby?

I know I've written about the magic of the white coat before but mmmboy, this is the real deal. As I wandered around the grocery store after finishing up my session, I realized I was holding myself a bit differently, like I had to appear more responsible - like someone who could ask you to drop your pants and you would know that it was for a good reason, or like someone to whom you could talk to about being sad in jail, even if you're a huge man, or like someone with whom you would trust your baby, even as I go to drop him on the exam table.

I keep looking around wondering when anyone is going to pick up on the fact that I have no idea what I'm doing, but then I realize, well, maybe I'm starting to...

Sunrise Hike!

This morning I woke up at 3:15 am, picked up a few friends, met a few more friends, and drove to a mountain just 30 minutes out of town for a sunrise hike. There were a few more cars of friends coming to meet us, but since we could see the faintest glimmer of a sunrise, we decided to start hiking and meet them at the top. When the eight of us reached the top, we breathed deeply and took in the amazing view around us as the sun peaked over the mountains.

A few minutes later, about 15 more of our classmates came up the mountain behind us - it was incredible. I'm not sure if it speaks to how amazing our class is, or how depraved our souls feel that a quarter of my medical school class decided (impromptu) to wake up before sunrise and hike up a mountain, before class!

We ate some home-made muffins, did some yoga stretches, then all lined up and one friend led us in a "Bonzai" salute - a celebration done on Mt. Fuji at sunrise by pilgrims and visiters, where you raise your hands to the sky and scream "BONZAIIIII" as loud and as long as you can. It was a beautiful thing.

Then we read some poetry, took another deep breath, and hiked back down. We grabbed some bagels before heading into class, wired and ready to go (okay, so half the people skipped class and went to take a nap - we're not robots). But I felt invigorated for the rest of the day.

One of the poems we read:

The Sun (by Mary Oliver)

Have you ever seen
anything
in your life
more wonderful

than the way the sun,
every evening,
relaxed and easy,
floats toward the horizon

and into the clouds or the hills,
or the rumpled sea,
and is gone--
and how it slides again

out of the blackness,
every morning,
on the other side of the world,
like a red flower

streaming upward on its heavenly oils,
say, on a morning in early summer,
at its perfect imperial distance--
and have you ever felt for anything

such wild love--
do you think there is anywhere, in any language,
a word billowing enough
for the pleasure

that fills you
as the sun
reaches out
as it warms you

as you stand there,
empty-handed--
or have you too
turned from this world--

or have you too
gone crazy
for power,
for things?

a neurosurgeon and an alcoholic

What's the difference between shame and guilt?
With guilt, you feel like you made a mistake, with shame, you feel like you ARE the mistake.


So began our session this evening about physicians and substance abuse.

An orthopedic surgeon came to talk to our group of seven about his experience with an addiction to pain medication - and talked about how the first time he ever felt "normal" was when he had a shot of demerol (a narcotic used to treat pain) after having knee surgery as a 15 year old. When we asked what "normal" meant, he thought for a moment and then said, "comfortable in my own skin", "not anxious", and "calm". These are qualities that all 15 year olds crave perhaps, but they are also not qualities that medical school or the entire process of becoming a doctor really supports. In fact, a lot about the process is incredibly uncomfortable, you're put on the spot all the time, and it could hardly be described as calm - physicians are often involved in the most crazy moments in peoples lives - and yet have to remain calm.

And we're not supposed to talk about it either. There's a necessary confidentiality that comes with having access to people's most private details, but it's hard when there is no one, not even colleagues, with whom to really process what goes on in ones day. And while it's improving, there is very little space given to processing the complicated emotions that come with caring for peoples lives. It's sort of hoped that medical school and all its training will prepare us to somehow magically be able to internalize these emotions and maintain steadiness when everything around us is going crazy. Yet there's also not a lot of time to create or maintain a support network.

In one of the excerpts we read to prepare for this discussion, the author attends an AA/NA meeting for physicians - and the group goes around and instead of the normal (?) Hi I'm Joe and I'm an alcoholic", they start with their profession first:

I'm Joe and I'm a neurosurgeon and an alcoholic. I'm Jane and I'm an orthopedic surgeon and a narcotics addict. I'm Bob and I'm an anesthesiologist and a cocaine addict.

They also say (and the physicians who spoke to us reiterated) that the work is the very last thing to suffer, so it's not always clear to colleagues that something is going on. that's pretty scary, especially because personal details are not really encouraged so much in medicine - it makes you a bit too human to be asking to put our fingers in someones rectum - or something...

I feel very lucky to have deep friendships with people both in and out of the medical field with whom I feel comfortable processing - but man, is it tough already, and I'm not even really expected to do much of anything yet. I can't imagine next year.


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"like so many of us, perhaps he was drawn to doctoring because he subconsciously thought that if he attended to the pain of others, it would take care of his own"
-Abraham Verghese (in his book, the Tennis Partner)

spinal cord injury & marathon training

It's winter and a young girl in a wheelchair rolls up to a snow-covered school and stops at the entrance will all the other kids, staring at snow-covered stairs and a snow-covered ramp to the front door. A janitor has started shoveling the snow on the steps. When the girl asks him if he can please shovel the ramp, he says, "not until I'm done with the steps, you can't always have priority for your disability, you know". To which the young girl in the wheelchair replies, but if you shovel the ramp, we can all get in.

It's a story directly stolen from my mother, who tells it when she gives discussions on adapting to people with disabilities. I thought of it today because our entire day (and maybe week?) is focused on spinal cord injury, and this afternoon we had an orthopedic surgeon and two of his patients, a young man and a young woman with spinal cord injuries, present to our class our next "case". They went through the basics of spinal cord injuries - what sorts of fibers are destroyed depending on which level of the spinal cord is affected, and how these manifest in symptoms such as an ability to control ones bladder (which is pretty much not possible for anyone who seriously injures her/his spinal cord, regardless of the vertebral level), ability to sit up straight (difficult if the injury is higher), ability to feel ones toes (really depends).

The man and woman (let's call them M. and C.) were incredibly charismatic, open, and educated about their own injuries and their lifestyles before and after. As an entire class (we're talking 100 some people), we talked about everything from "bowel programs" - or the methods by which they empty their bowels, and actually teach their bowels to empty at certain times - to sexual climax and how their are erogenous zones everywhere, and an orgasm is much more mental than we all think it is anyways. M. talked about his battles with skin sores, some of which go all the way to his bones - something I never think about when I think about the challenges of being in a wheelchair many hours of the day. C. talked about how she used to ride horses, how menstruating is actually basically the same, except that she cannot take a hormonal pill because people in wheelchairs are at a greater risk of clots, and how she's training for the marathon and still riding horses.

They both talked about how their wheelchairs had become a part of their bodies and how incredibly rude it felt when health care workers (or other people) leaned on them, pushed them, or generally touched them without permission.

Our class was completely captivated - we asked about a million questions and when they finally had to finish the session (30 minutes late), we clapped so hard and then went down to ask them more questions.

*********

It was fascinating to have this subject matter come up this week because a good portion of my class is training for our city's marathon, and last week was our 18 mile run, and this week is our 20-mile run, the longest run ever for a lot of people. We're all hurting a lot and there are lots of doubts about whether our bodies are up to the challenge, but after learning about the abilities of all of our nerve fibers - and how much people do even when some of them don't work, I feel a lot more motivated to get out there and take advantage of my body's abilities, as well as to be a little more forgiving of it's disabilities.

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"Put yourself in a state of mind where you say to yourself, 'Here is an opportunity for me to celebrate like never before, my own power, my own ability to get myself to do whatever is necessary.'"
-Tony Robbins

I am an emotional creature

This week begins our final "block" of classes, called "Neural Sciences" that is basically a complete structure and function of the brain, along with learning the pathophysiology of diseases. Our course director began her Introduction lecture, as most course directors do, with the objectives of the course. These usually include "learn and understand the structure and function of XX organ systems" and "understand the basic molecular mechanisms of disease in XX organ systems" - she included these. But she also included at the end: to make you, as future physicians, more aware of and more impressed by mental and psychiatric health.

She went through a bunch of comments made by physicians that are disparaging about working in mental health - such as "you want to be a psychiatrist? but you're so smart!" or "why would you do that, it's not even real science!"

It's scary to think how little psychological state and emotional state factor into our health CARE, even though they often are the greatest factors in our HEALTH.

I saw a video on ted.com of Eve Ensler, the write of the Vagina Monologues (and numerous books) called "I am an emotional creature" that just said it straight and, like Eve Ensler always does, blew my mind.

Check it out:
I am an emotional creature video

In medical school, we're taught to defy our needs (sleep, food, space), to ignore our emotional responses to things that are huge like death and life and pain and love. It's good to remember that embracing those can make us better doctors, better people, and that repression of them is not always good science.

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“My short skirt / is not an invitation / a provocation / an indication / that I want it / or give it / or that I hook. . . . My short skirt is happiness. / I can feel myself on the ground. I am here. And I am hot.”

-Eve Ensler