My Scrumptiously Random First Publication

In my pathology classes, I examined the slides under the microscope like clouds in the sky, searching for familiar shapes. Late nights in the library, while sifting through books and power points, I would find succulent surprises. References to onions, cherries and other delicacies were hidden among the medical terms, describing the gross, microscopic or radiographic features of iconic disease states. I began a collection of these food-related terms. My family quickly learned of my new hobby and officially banned medical terms at the dining table. They did not want to hear about current jelly as it related to bowel movements of children.

In the December issue of the Malta Medical Journal, Dr. Masukume and I have “cherry-picked” classic food-related terms in Pediatrics, providing a feast for the senses. Intussusception is the most obvious example from our list, as it “packs a punch” with four food-related terms.

Intussusception occurs when one section of the bowel abnormally goes into another segment of bowel, similar to one section of a telescope folding into another. This causes obstruction and strangulation of the bowel, causing the stool to consists of mucus mixed with blood, resembling the appearance of red currant jelly. Physical examination may reveal a “sausage-shaped” mass upon palpation of the abdomen. Transverse imaging will reveal the “doughnut sign” and longitudinal imaging will revel the “sandwich sign.” These four terms, along with some other hallmark facts (most common form of bowel obstruction in children, typically occurs between 3 months and three years, pain relieved by squatting, involves the terminal ileum) clearly point to the diagnosis of intussusception.

Without the comparisons to food, intussusception would be another malady to memorize in quite a long list. I have now collected over 300 medical terms related to food. From fish to blueberry muffins to potato chips to strawberries, medicine is sprinkled with these metaphorical crumbs, making learning much more palatable.

To find out what medical problem could possibly be compared to a potato chip, and to see my artwork, make sure to read our article!

Surgical Life

Surgery in the winter was like living without the sun. I would wake up at 3:30 or 4 in the morning, chug some coffee, shovel out my car in the black of night, and drive myself to the hospital. I would check on my patients, write some notes, and meet my team for rounds at 5:30am. By 6:30, we would all end up at the cafeteria for what I liked to call Second Breakfast and to "run the list" of patients with the whole team. Chug more coffee, egg and cheese sandwich, then off to the OR!

I spent about a week on each team: Vascular, Pediatrics, Minimally Invasive, Surgical Oncology, Private Surgery. And every once and a while, my pager would go off and I'd race to the Trauma room to learn my ABCs - Airway, Breathing, and Circulation, or to see the result of some horrific accident. Trauma pages were always interesting, and never happy.

Operating was exciting at times, but usually I practiced my Surgical Watching Skills. As a third year, I was on the very very bottom of the Surgical Totem Pole. If I hit the jackpot, I'd get to First Assist, and perform surgeries! I amputated a right leg and a left big toe, stitched a carotid artery with tiny little needles, placed endoscopic ports, cut off chunks of colon, and performed an anal wart removal (woo hoo!). On a normal day, if I was lucky, I'd get to suture wounds closed at the end of the case, or hold the scissors or the suction. But like I said, most of the time, I'd spend the surgery standing, watching and waiting - ready to help at any moment. Debating whether or not to move my hands or pick up a tool. On a bad day, I'd be placed in an awkward position, intertwined with a surgeon or nurse, holding retractors at impossible angles, and yelled at if I touched anyone and contaminated them. My muscles would burn and burn, but the surgery depended on my discipline and steady grasp.

At the end of a day, after some lectures or sign-out (sometime between 5 and 10pm), I would head back to my car, again without the sun.

I worked about 70 hours a week on average (that means 12hrs daily M-F + 10 hours on the weekend). As a medical student, I have an 80 hour limit, and finally learned just how exhausting an 80 hour work week could be.  I completely gave up on my personal health. But honestly, my surgery rotation was one of my favorites - and even had me considering a future as a Surgeon. I learned so much so quickly and actually had a ton of fun roaming the halls of the hospital like I was on an episode of Scrubs.

If I do a Surgical rotation during 4th year, I just hope I see a little bit more of the sun...

Cold and Dark and Sick and Psychiatry

Winter has been cold (Polar Vortex Cold). And dark (Sun Sets at Four Dark). And exhausting. I caught a cold on Pediatrics (as expected) and am in bed sick again today.  Being sick (twice now) really tips me over from a high-functioning medical student to a unorganized wreck.  I quickly unravelled from being able to cook all my meals, pack lunches, exercise, study daily, take care of patients, finish my notes on time, make all deadlines, and have time for side projects to barely meeting the requirements of my rotation and falling apart when I have to write an MPH paper or go away for the weekend.  I guess I have a limit, and am able to handle all of these responsibilities until I get sick. Then it becomes too much. Poor Lisa.

A college friend and I used to scold each other when we would get into similar ruts, and tell each other to "get over your life dysmorphic disorder," or LDD.

Body dysmorphic disorder is a true psychiatric illness in which the patient has excessive concern about and preoccupation with a perceived defect of their physical appearance, despite appearing normal to others. These patients are inconsolable, and feel like they are deformed. Extrapolated, I am still functioning and in all honesty have a wonderful and amazing life, but here I am complaining and worrying and dwelling on a perceived defect in my life (being sick), therefore I have LDD.

(You will not find LDD in the DSM-V, the diagnostic guide to mental disorders that I have been using daily on my Psychiatry rotation.)

Alright, so we were being a bit insensitive. People suffering from body dysmorphic disorder aren't just complaining (like I am), they are really sick. But she was right that in my ruts, like this one, I shouldn't focus on the small things that I perceive as defective or negative (*I can't believe I slow down when I get sick*), and need to be more appreciative and realistic (*Everyone slows down when they get sick, chill out!!*). Clearly I respond to cognitive behavioral therapy...

Goldilocks and the Three Kiddos on Pedi

Time flies when you are having fun, and my Pediatrics (or as they like to say, Pedi, pronounced "P.D.") rotation was over before I knew it.

I had a blast on Pedi. Most memorable patients included:

A 9-year-old girl who was born with her heart on the wrong side of her chest who had a mysterious blood infection, either from her heart or her ankles. The treatment was the same regardless, so I guess we will never know. We wrote secret messages to each other on the chalkboard on the floor. She also gave me this notebook (see photo). 

A 5-year-old girl with adorable glasses and pneumonia. She refused to take her medicines, so I made her an offer she could not refuse. I let her squirt soda at me using a syringe that she used to drink her antibiotics. Luckily, she was contagious so I was protected by a plastic gown. To help her get air into her lungs, we had her blow bubbles all day. 

A 20-year-old Spanish-speaking girl with Down Syndrome who was newly diagnosed with diabetes and loved to shake my hand every time I entered or exited her room. I spent a lot of time trying to find her something to drink that wasn't so sugary...

One of my Pedi attendings kept referring to Goldilocks and the Three Bears, warning me not to do too little or too much, but to do JUUUUST the right amount of medicine to make my little "kiddos" get well again.

(On Pedi, all the patients, ages zero through 22, are Kiddos. One of my classmates postulated that they were all Kiddos because the residents couldn't remember their patient's names. Or for the babies, because nobody knew if the Kiddo was a He Kiddo or a She Kiddo... I hope it's just because a Kiddo is obviously better than any other type of patient.)

All of medicine is playing Goldilocks and the Three Bears, not just in Pedi. We had a lecture on big bad Medical Malpractice last Wednesday. I have seen some Malpractice in my time at Baystate, and it looks a lot like doing too little, or doing too much. But it is not easy to do JUUUUST the right amount of medicine. It seems pretty impossible to me.

When a patient (or Kiddo) shows up in the Emergency Department with some vague complaint, the doc asks a bunch of questions and then runs a bunch of tests. In some cases, the doc starts a bunch of treatments, too, even before they have the diagnosis. The tests have risks. The treatments have risks. Just being in the hospital for too long, without us even doing anything, has risk. But not doing the tests and the treatments could have worse and sometimes fatal consequences. Doctors base their decisions on the most common and the most dangerous things that someone could have based on their story and physical exam. They try to do JUUUST the right amount of medicine.

That is what I am learning as a third year. Medical management. How to make these doctor-y decisions. Luckily, on Pedi, Goldilocks and the Three Bears usually meant something a lot less intimidating, and involved porridge and tucking a Kiddo into bed.

I am being brainwashed.

I have finished over half of my third year of medical school. I know some things now.  And like the rest of my classmates and thousands of other medical trainees around the world, I am being brainwashed.

Medical school administrators like to refer to this brainwashing as "The Hidden Curriculum."  Dr. Wikipedia (AKA the website, which I have seen many doctors consult) claims that The Hidden Curriculum is a "side effect of education."  While we are being slammed with medical facts and lab values, our supervising doctors and residents are brainwashing us with the culture of medicine.  We are becoming doctors, complete with stereotypical doctor personalities.

When I was on my Family Medicine rotation, I preached the value of primary care. I repeatedly encouraged all of my friends to get appropriate preventive screenings and motivationally interviewed anyone with a cigarette or obesity who crossed my path.  On my OBGYN rotation I tried to convince my little sister to get a particular birth control without listening to what her preferences were, rolling my eyes when she disagreed with me because the one I suggested "was the best."  While rotating in Internal Medicine, I began quoting famous journals and speaking with as much medical jargon that I could feasibly fit into each sentence, even when talking to non-medical family members.  Looking back, I feel like I have been rotating through personalities, changing to blend into each specialty. Looking around, I see the majority of my classmates doing the same.

While I have painted a somewhat negative picture of The Hidden Curriculum, I have also had the opportunity to try on some wonderful doctor-like attributes.  While sitting in on clinical encounters with each physician or resident that we work with, medical students encounter contradictory hidden lessons on how to act like a doctor.  Each doctor is different, but the more we see, the more we are supposedly affected.  But affected how?  I have met terrible people with disgusting doctor personalities, yes, but more often I have met beautiful and compassionate people.  People who want to help other people, people who are curious about the world and how things work, people who strive for excellence no matter how small the task.

Let's be realistic, here.  Like any other field, we can't put all doctors into one giant category.  Sure, each specialty has its stereotype, but I have again and again found that the stereotypes aren't always (at least not completely) true.  I almost welcome The Hidden Curriculum as an opportunity to sort through my options and chose my favorite doctor characteristics that I will carry with me (and leave the bad characteristics behind).  Not to mention an opportunity to sort through the specialties and decide which one fits with my beliefs, my attitudes, my personality.

I think medical students have a choice. We can chose to take on personality traits of the doctors around us and become brainwashed to fit the stereotypes that we see. Or we can chose to tailor The Hidden Curriculum to our own personalities and learn the traits we want to keep, and the traits we want to rotate away from.

Dying for an Autopsy

During my Pathology elective at Tufts Medical Center, I accidentally told the head pathologist that I was DYING to see an autopsy. Poor word choice. He gently reminded me that an autopsy means that someone did in fact die, and my learning would be at their demise. Pretty glum. My last day of the elective, I did get to see the autopsy that I was dying for, and I definitely felt like I had cursed the man that I met on the table.

Pathology, literally meaning "an account of suffering," is the study and diagnosis of disease. The pathologists work in a quiet little factory deep in every hospital, where no (living) patient can be found. The pathologists are handed body parts, organs, tumors, moles, lumps, and other unidentifiable pieces of humans and are tasked with figuring out what these pieces are and what went wrong within them. Pathologists can also become medical examiners, who do autopsies to determine cause of death. They run microbiology labs, run tests on your blood, and determine who you can get transfusions from.

The grossest (haha - pathology pun) thing that I saw was "pseudomyxoma peritonei," caused by a mucinous adinocarcinoma of the appendix. The specimen consisted of three buckets of mucous drained from somebody's abdomen, along with a mucus-covered spleen, a mucus-covered piece of bowel, and a mucus-covered piece of liver. I also got to dissect a teratoma, or a type of ovarian cyst that can sometimes contain bone, teeth, hair, sweat, or fat. The head pathologist mentioned that he once dissected a teratoma in which he found a little scull with hair coming out of it. He said that it looked like a troll. Human bodies are incredible, and while all of the diseases we diagnosed were sad, I was amazed that these things were coming out of real people.

 

The process: 

(1)   Get a specimen. Usually in a jar in a biohazard bag. Usually from a surgery or a biopsy
(2)   Gross dissection. Measure the specimen. Describe its color and consistency. Bread-loaf, or cut it into slices. This had to be done in a specific way, depending on what we were slicing.
(3)   Take samples. We would sample anything weird (like a dark spot, a mole, a tumor) and then take samples from different parts. Sometimes we sampled the whole specimen. Samples went into "cassettes" which we would fix in formaldehyde overnight. 

My placenta slide, the "cassette," and some views under the scope

(4)   Make slides. Histology techs would take over. They finished the fixing, embedded the samples in parrafin wax, cooled them, sliced them on a microtome, and adhered the slices onto slides. They would then heat-fix and stain the slides, add cover slips, and bring the freshly cut microscopic slides back up to the pathologists
(5)  Diagnose. The pathologists would then (rather impressively) look at the slides under a scope for maybe 10 seconds and make a diagnosis. All I saw were shapes, colors, lines, and maybe sometimes a familiar cell. But the pathologists would immediately know what tissue the slide came from and what the pathology was. Definitely a cool skill that I did not pick up during my two week elective.'


Thanks to a lot of begging and friend-making on my part, I got to attempt every step of this process, and made my own slide out of a placenta!! It took me forever to slice the tissue thin enough, transfer it to a water bath, and get it on a slide, but I DID IT!

 

The autopsy

I walked into the room and met our patient, a cadaver. Now I have taken gross anatomy and have seen a few cadavers in my day, but never one that was so life-like. I guess you could say he was fresh. He looked like he was sleeping. And he smelled like rotten fish. The deiner, a funeral home-trained body cleaner, started ripping him into pieces. I could get realllllly graphic right now, or I could just say that she ripped out EVERYTHING. And it wasn't graceful. Fluids everywhere. The worst part was probably when she eviscerated him. Or maybe when she took the skin off his head to saw off his scull cap and remove his brain. All while chatting about her life, no big deal. Just another day cutting dead bodies into smithereens!

Two and a half hours later, we were done. We weighed, analyzed, cut samples from, and inspected every organ in his body, from brain to testicles. The deiner put him back together like nothing had ever happened. The only evidence were two cuts - a Y-shaped cut from his chest to his abdomen, and one on the back of his head from ear to ear. Neatly stitched shut.

The head pathologist treated the case like a mystery; searching for signs of disease and figuring out how our patient's history during his life could explain his cause of death. Turns out that he died of heart failure and fluid overload. I was able to inspect his organs one by one and learn how heart failure changed the way his body functioned. And although I absolutely appreciate the experience, I won't be dying for another autopsy anytime soon.

Guest Blogger: Surgery Feels, by Wendy

Please enjoy my second guest blogger, with #stuffwendysays about surgery rotations.
-Lisa

The last 8 weeks (i.e., my surgery rotation) have taught me amazing things about the human body. I've learned more about anatomy, physiology, and medical management in that short time than I could have imagined, and what I did know already has become that much more intuitive.

I've seen a risky emergency go from near certain failure to amazing success, felt people's organs from inside their abdominal cavities, put in staples and sutures, held a 93 year old man's hand while he got a chest tube placed, talked to amputees, given patients popsicles, and watched a man learn that he had metastatic cancer after what he thought would be a routine operation. I've worked one-on-one with some surgeons while the residents where in conferences, what is known as "first assist", and stood at the back of a crowded OR, trying desperately to see what was going on but knowing that it was more important to keep the patient alive than for me to be learning just then.

Patients have thanked me personally, and asked not to have medical students in the room. Attendings have looked at me like I was too stupid to exist, and praised me for getting a tricky question correct. This rotation has been amazing, disheartening, the coolest thing I've done, and I'm so damn glad it's over.

Things I've learned:

- Always wear a helmet. Specifically, when you're biking or riding a motorcycle, but it seems like it would also help if you're elderly and plan to stand up, like, ever.

- Specifically: well-fitting bike helmet, motorcycle helmets with full face protection

- Don't ride your motorcycle in shorts and a t-shirt even if it's hot out

- Maybe just don't ride a motorcycle

- Stay the hell away from where the bike path intersects Mass Ave in Lexington

- If you're having BRBPR (bright red blood per rectum), just tell us if this occurred soon after trying anal intercourse for the first time. We're really, really, not here to judge.

- Really large fibroids can feel like your patient is surprise!pregnant or has a reeeeallly full bladder on physical exam.

- If you don't secure a J-tube on the outside of the patient in some way, it can decide to fall in and then someone will have to fish it out again and the patient will be sad.

- Occasionally you will actually get a 40-something year old obese woman with 4 kids coming in complaining of RUQ pain, and be like BOOM, mneumonic!

- Diabetic foot ulcers have a really characteristic smell.

- While it would be an amazing coincidence if one were to incidentally diagnose a subungual melanoma the day after a conference on skin lesions, it is more likely after getting some history that the patient (a construction worker) whacked his hand with a hammer last week.

- In a patient with a fall involving hitting her head, don't immediately freak out if one of her eyes has an unreactive pupil. Since she is awake, communicative, and in no apparent distress, she may be happy to tell you that it's a glass eye.

- Crafting skills have some crossover for suturing and knot tying, but I'm pretty sure I'll never look at embroidery in the same way again.

- If you are caring for your patients well enough, they will start asking you things like, "do you even get to go home?" and "how many days do you work here?" and you will feel simultaneously proud and awful.

- It is important to take this to heart during your surgical rotation: eat when you can, sleep when you can, pee when you can, leave when you can.

- Who am I kidding, you don't have time to do any of that nonsense. Load your pockets with free crackers and dream of the day when you can sit down.