Science From Afar Melody can be reached at melo.ko@gmail.com April 25, 2012 Running, Puffing and Scratching I hate running. I have always hated running and look at those who breeze through miles and miles with envy and bewilderment. How do they do it? I can barely run to catch the bus without getting out of breath. Don’t get me wrong. Being a doctor, I know that regular exercise is crucial to maintaining good health, and I do try to stay active by going to the gym and hitting the dance floor. But until recently, I have always avoided the treadmill like the plague. Curiously, I can stay on the elliptical machine for over an hour at a decent speed, but running on that conveyor belt, or anywhere for that matter, just makes me absolutely miserable. I run out of breath, quite literally; my joints start to ache from old injuries; but what really drives me up the wall, or rather, off the treadmill, is something called exercise pruritis. Pruritis means acute itching. And although it can be as distressing as pain, or even more so in its severe form, research in this area is only in its infancy.  I couldn’t really find any literature on exercise pruritis, although I did come across case reports and study of exercise-induced anaphylaxis – a severe and quick onset allergic reaction to exercise characterized by skin rash, low blood pressure and swelling of the airway that can be lethal. Luckily, what I experience is much more benign. In fact, the only skin changes I see is some mild redness. But that does not prevent me from scratching so hard that I leave purple bruises on my body. The pins and needles sensation usually starts in my thighs and buttocks five minutes into my run. By the seventh or eighth minute I look like a manic scratching monkey. The one time that I made it to ten minutes without stopping, the manic monkey was on steroids. Allergic reactions occur when a chemical called histamine is released from mast cells in the body upon exposure to an “allergen.”  This triggers a cascade of events that result in inflammation, swelling and itching.  But it is also possible for histamine to be released in response to a physical stress like running or a change in temperature.  It makes sense then that blocking the action of histamine is the mainstay of allergy therapy. That is what over-the-counter allergy medications such as Benadryl (diphenhydramine), Reactine (cetirizine), Allegra (fexofenadine) and Claritin (loratidine) precisely do. I have tried taking these medications before a workout, but to no avail. However, I was not willing to give up. Terry Fox, and several others after him, ran with one leg and one prosthetic. I am young, healthy, have two functioning legs, and I can’t run for a few minutes? So I decided to keep at it, even if I have to take regular breaks, running, puffing, and scratching. First off, though, I had to get a new pair of shoes. My mom’s old sneakers had accompanied me on the rough pitted roads of Grenada and then the tough asphalt of New York City. They survived blood and iodine stains from my shifts in the Emergency Department. But after years of abuse, they had finally disintegrated beyond repair. I cannot remember the last time I went shopping for running shoes, and was flabbergasted by all the science that goes into designing them. For example, specific soles and cushioning are designed based on whether you are a pronator (roll your feet inwards) or a supinator (roll your feet outwards). And then there is the craze about the novel “Barefoot” running shoes that are so thin they feel like you’re not wearing anything. I am no running expert; quite the contrary. But I am rather injury-prone, so I decided that I should get a good pair of shoes. After consulting with a few of my more athletic friends, I settled on a pair of Asics. So with my new pair of running shoes – and these are not just any shoes – they were chosen for me by the seemingly expert sportswear specialist at the Asics store for my specific foot shape and gait, I hit the gym and strode away on the treadmill a few minutes at a time. Then something extraordinary happened yesterday. There was still puffing, but no itching and no scratching. I watched for the five-minute mark on the treadmill’s red timer, nothing. Six minutes, nothing. I felt no itch. It was miraculous! What happened to my mast cells? Then I remembered that I had been taking a 10 mg dose of cetirizine everyday for hay fever. Perhaps taking an antihistamine before a workout was not enough, but a daily dose ensured that I had an optimal concentration of the active ingredient in my system. Like many scientific breakthroughs, my little discovery was incidental. But science dictates that results have to be repeatable to eliminate anything that might have happened by chance. So with my n=1 (subject number of one person), I will further explore whether a daily dose of antihistamine is the answer to my itching woes. This is very exciting news for me. With the pruritis out of the way, I can now focus on improving my cardiorespiratory capacities. I won’t be signing up for any marathons anytime soon, but a 5K race doesn’t seem so out of reach now! But before the 5K, let me double check that I can do the 5 minutes first!           March 31, 2012 Distance Makes the Heart Grow Fonder For the past couple of months, the whirlwind of residency applications, letters of recommendations, interviews, the Match, uncertainties about life and trepidation about what is to come had me so dizzy that I lost track of why I am doing this. This, becoming a doctor. As my dear friend Mustafa who is about to finish his residency once told me jokingly: “My parents told me a big lie. They said that all I had to do was to work hard, become a doctor, and everything would be fine. I worked hard, I became a doctor, and everything is not fine.” What he meant was that the hardship does not end the minute we get accepted to medical school, as I once so naively thought; nor does it end after we graduate. Exams keep on coming even though school’s out forever. After med school there is residency during which you compete for fellowship, then comes the job search which is not as easy as some depict it to be. I know, because I see it everyday. I must admit that I was, for a while, plagued with self-doubt. Life has not turned out the way I had planned it to be, and being goal-oriented, I had trouble accepting not meeting my goals exactly the way I had pictured them. Why do I even want to be a doctor? Sometimes, it takes a bit of distance to see the big picture. I left New York City a week ago to come back to Montreal to reconnect with friends and family before the real grind of residency begins this summer. During this time, I tried to put the world of medicine out of my mind. Funny thing, that’s when I started to love medicine again.   I attended a lecture on “pain” at McGill University, and I marvel at how much I have yet to learn and I cannot wait to start exploring this deep pond of knowledge! And then I remembered the belligerent man with the rotting legs who eventually showed a softer side, the lovely old lady who coded in the E.R. after she told me I would make the best doctor in the world, the old blind man whom I accompanied home after he visited his dying wife in the hospital; they are the reason I am doing this. I am so glad I picked this career. But as in any relationship, some space is good. So during my time off, I am offering myself a trip to South East Asia as a graduation present, am continuing my birthday festivities although it has been two weeks (accepting gifts at the OSS address), and reading books that I don’t have time to read otherwise. Life is good. And I get to spend mine helping others to have good lives, too.      Performing magic at Montreal Children's Hospital         March 18, 2012 Chin up Last Monday was the long awaited day! The Match! That’s when med students find out where they will be spending the next couple of years; if they match! If not, it’s a long year before another chance comes around. Monday came. Phew! I found out I matched. But it would not be until Friday that we would find out exactly where we would be heading. The night before the final result, I could not sleep and went to the gym at 11 P.M., and then again at 4 A.M. to relieve my stress. If only I would work out like that everyday, I would look like a super model. Yeah, sure. Friday March 16th, at 1 P.M., I opened my email gingerly, as if afraid of shattering something fragile, but also with great hope and cautious optimism. And there it was: I matched into a position as an Internal Medicine resident at Lincoln Medical Center in New York City. At that moment, what was shattered was not my computer; it was my dream of becoming an Emergency Medicine physician. I stared at my computer screen for a while, at first confused, then my heart started to sink. I knew that Emergency Medicine is quite competitive, especially for foreign grads; Program Directors have told me “We like you but we’ll take an American grad before a foreign grad, so let’s see what happens,” which is frustrating, but I guess understandable. But I also thought that I had a pretty good shot at it. After all, I received high praise during my Emergency Medicine rotations, and I thought my interviews went well, although that could just be my hopeful perception. Maybe I let myself hope too highly, but I had already let myself imagine working in an Emergency Department, running happily in the chaos, coming to patients during their most dire needs, resuscitating one patient while another shouts in the background demanding Percocet. I also envisioned taking my skills on international humanitarian missions. Just thinking about it brings a smile to my face. There were tears, cries, phone calls, and consolations. “At least you matched! Some people didn’t!” “It’s just because you’re Canadian, not because of your abilities!” “Everything happens for a reason!” “Emergency Medicine is not good for women anyway, it’s too stressful!” “You’ll still get to be a doctor!” Despite people’s best intentions, some of their efforts to console made me feel worse. And although irrational, I was still heartbroken and my lacrimal glands very much active. But I also know that most of them are right. What is not broken is my will to be a physician, to heal, and to comfort. As I sit here and ponder the future, I’m starting to think that Internal is really the heart of medicine. In no other specialty are you as likely to see such a diversity and complexity of ailments.  And I’ll get plenty of intellectual stimulation. So I will dry my tears, end the self-pity, keep my chin up, and be the best that I can be. Who knows? I might even be glad in the future. Guess what? This summer one journey ends, and another begins. I’ll finally be a doctor! Internal Medicine, here I come. With enthusiasm.             March 14, 2012 I'm a Doctor. Trust Me, Not the Quakcs. Being a doctor, or even a medical student, means that friends, family members and roommates will inevitably ask you for medical or nutritional advice. I don’t mind giving quick and free medical advice when I can. Funny thing is, they’re likely to ignore what I say if it doesn’t coincide with their preconceived notions. My roommate, for example, who is sharp in finance but is scientifically challenged, believes that detergent residues on dishes cause cancer, which is why she only washes her dishes with water. (Ironically, she will indulge without hesitation in cigarettes, fast foods and whiskey.) She stands by her beliefs even after I tell her that traces of detergent are highly unlikely to cause any ailment, and that there are many other things she can modify in her lifestyle that will be much more beneficial in safeguarding her health. Perhaps I am lacking in the art of persuasion, but when it comes to science, it is not about persuasion, nor about faith. It is about facts. My Bachelor of Science undergraduate degree, my four years of medical training and especially my involvement with the McGill Office for Science and Society for almost a decade have taught me to have a very keen eye for spotting quackery. It isn’t always easy to recognize because quackery can masquerade as science.  Anyone can be taken in, even me. When a Youtube video (see here) about Japanese scientists creating artificial meat by recycling fecal matter went viral on the Internet, I bought it.  Not the poop, the science. The idea wasn’t so implausible, after all. It turned out to be a spoof. Pranks such as the Japanese Poop Burger are more or less harmless, and are good for a laugh. I was amused and somewhat chastened by my own gullibility.  But there are too many claims and promises out there are not only false, but dangerous. A friend recently told me that she learned from a supposedly scientific source that a vegan diet not only prevents, but also halts or even reverses numerous diseases, including cancer. If you already have cancer, she says, and you adopt a vegan diet, then your cancer cannot go past Stage II. And then my friend added that her friend who is studying nutrition agrees. At the risk of sounding arrogant, which truly is not my intention at all, I do not have to do any research to know that cutting out meat and dairy from one’s diet to stop or reverse cancer is wishful thinking. It just does not make sense. More importantly, there is no evidence for it. Telling a patient that his coronary artery disease will be totally reversed if he adopts a vegan diet, or advising a cancer patient that her cancer cells will only multiply to Stage II if she eliminates animal protein from her diet is unscientific. Moreover, I believe that spreading unfounded claims is criminal. This is not to say that diet cannot play an important role in dealing with disease, but suggestions that that cancer can be beaten by following some sort of dietary regimen is not only unrealistic but can distract from effective therapies. I don’t think I did a very good job at explaining the importance of following the scientific method to my friend. Neither did I get the message of “only the dose makes the poison” across. Perhaps I take the need to rely on evidence too much to heart and I get prematurely upset by those who instead rely on faith or hearsay, especially when human lives are at stake. But at least in my friend’s case, being young and healthy, a decision to forego fatty burgers and fried eggs for two weeks as a “cleanse,” is no big deal. But what do I do about my future patients who are seriously ill, and who obstinately choose to follow their beliefs or the latest health fad, which might or might not be of any benefit, instead of following sound medical advice? How do you fight your patients from being seduced by supposedly miraculous remedies offered by doctors or scientists who have gone over to the “dark side,” either succumbing to self delusion or the promise of financial gain? That is something they don’t teach you in medical school.           February 27, 2012 "CHOP," what does it stand for again? Almost every day in medical school has its ups and downs. First, today’s “up.” I was complimented by a “Fellow!” That’s a doctor who has completed residency and is undergoing additional training in a subspecialty. My presentation at rounds, he said, was better than that of the residents. Now that’s the kind of stuff that boosts your mood! But it wasn’t long before the “down” appeared, flooding me with a feeling of inadequacy and incompetence. My current and last rotation is in Hematology and Oncology. I don’t know why hematology and oncology are combined as one specialty. There is some overlap to be sure, but there are marked differences. One deals with the disorders of blood, such as various types of anemia or clotting disorders, the other deals with cancer. There are of course cancers of the blood, and cancer can spread through blood, but at least to my novice eyes, being a hematology and oncology specialist is akin to being double specialized. So much to know! How can I ever learn all the available chemotherapies? How do I know which of the myriad protocols apply to which malignancy? Just about all I remember about chemotherapy from studying for my boards is the mnemonic CHOP. Even that I now had to Google to refresh my memory. It stands for four common chemotherapy drugs: cyclophosphamide, hydroxydoxorubicin, oncovin, and prednisone. We’ll see if I still remember that in a week. Now back to my “down.” Curiously, it was related to my “up.” I was assigned a patient whose case I presented, earning the praise from the Fellow.  But it was also this patient who made me feel totally at a loss. She came to the emergency department because of an episode of syncope, a brief loss of consciousness. It turned out that six years ago she had a similar episode and was diagnosed with laryngeal cancer. A mass was found in her throat that compromised her airway, causing a loss of consciousness from lack of oxygen. She was treated with surgery, radiation and chemotherapy and everything seemed fine until a few weeks ago when her voice started to become more hoarse and she began to experience difficulty swallowing. That’s a scary sign that something is obstructing the trachea. Incidentally, a “sign” is something an investigator finds, a “symptom” is what a patient reports. When I saw this lady, she was lying in bed in the Medical Intensive Care Unit, a slightly bloody tracheostomy tube sticking out her neck, helping to maintain her airway. She was too drowsy to answer my questions, so I spoke to her elderly parents. Well, it wasn’t exactly speaking because they did not speak a word of English. I tried to appear confident with my broken Spanish and my even more broken knowledge. Truth be told, I didn’t really know what to ask. Without imaging, we cannot be certain whether there is a mass in her throat, and without biopsy, we cannot tell if the cancer has come back. Has she lost any weight recently? No. Is she a smoker? Yes. Can I examine your daughter? OK. So I started without really knowing where to start. What do I look for in a patient who might have throat cancer? She couldn’t open her mouth wide enough for me to visualize her pharynx. I listened to her heart. Yeah, it’s beating normally, I think.  She couldn’t sit up for me to listen to her lungs, so I fumbled around with my stethoscope on the side of her chest. Yeah, she’s breathing normally, I think. I palpated her neck and felt something kind of hard on the left side but had no idea whether it was the tracheostomy tube, a mass or an enlarged lymph node. All this time, the parents looked at me expectantly and haggardly. I felt bad that I couldn’t give them more information and I wondered if they could tell I was more or less improvising. The only comforting thing I could tell them was that I would be back with the attending. Thank goodness I have residents, Fellows and attendings to fall back on! Two weeks until I get my M.D., and I don’t feel I’m ready to be a real doctor at all. But the Fellow tells me that’s the way all fourth year students feel. And that ends the day on an “up.” I look forward to tomorrow’s roller coaster ride.       February 17, 2012 Almost There, And Yet Still So Far Away! In less than a month, I will be done with medical school and school altogether. At last!  When I tell people about this, I am inevitably asked how I feel, whether I am excited. I am not sure how to put all my emotions and chaotic thoughts into words, but I will give it my best shot. Disbelief. From being a curious and inquisitive child interested in science and the human body, to the fateful day I made up my mind to pursue a career in medicine while riding on a bus in Cuba, to now, stethoscope around my neck, white coat hanging on my shoulders, fingers tingling from being so close to touching that diploma. It has been a long, long road, and I really cannot believe that I am almost there. Anxiety. I’m almost there, but where is that exactly? I have just created my Rank Order List, a list whereby I rank the residency programs for which I have interviewed in order of preference, while the programs do the same with their candidates. On March 6th in Canada and March 16th in the U. S., a candidate will be matched to a program via an algorithm depending on their respective list. That day where residency applicants will hold their breath until blue and then cry from joy or desolation, is fittingly called the Match Day. I agonize over my Rank Order List. A single click on the computer, a small tweak in the rank order could determine where I will spend the next couple of years of my life, and potentially change my life in a dramatic way.  I worry about where I will match, if I will match. Frustration. Girl from an immigrant family is determined to become a doctor and save lives after witnessing destitution in Cuba. Her relentless chase of her dream whisked her all the way to the beautiful island of Grenada and then to New York City, and now her dream is about to come true! Ok, let’s hold the Kleenex for a second here. Being an International Medical Graduate (IMG) is a massive pain in the posterior. And being in the American system while not being an American citizen is… well, I’m going to say like having a thrombosed hemorrhoid. Never had one, but I’ve been told that it is excruciatingly painful. The paperwork, the equivalency exams, the puzzling language in legal documents and on websites, the phone calls and emails, being given the chase-around with phone calls and emails, the visas… All that is enough to make one laugh and cry in the matter of seconds. No, I’m not bipolar, just a medical student having periodic mini meltdowns. Don’t worry, it’s normal. Grateful. Despite all my whining and complaining, I am so grateful. Grateful for my parents to have always prioritized education. Grateful for being given this opportunity to follow my passion. Grateful to all those who believed in me when I didn’t believe in myself. Grateful for always having found that small open window when all the big doors were closed. Grateful for those who helped me overcome my difficulties. Grateful for growing up in a country where freedom is often taken for granted, and in a city that prides itself in diversity and culture. Grateful for my health. Grateful for my future. Of course, once in a while, I can’t help but wonder. I had good grades, I had good MCAT scores, I had a good CV, and I had good letters. Wouldn’t my life have been so much easier had I gotten into a Canadian medical school? I wouldn’t have to worry about all this equivalency and visa nonsense. But they say that the harder the battle, the sweeter the victory.  No use in playing the what-if game. And as always, although the road may seem long and tortuous for now, I will keep on going and going and going, laughing and crying in between.         January 30, 2012 Spreading the Word, But Not the Virus Don't kiss me! Ever heard a girl say that to you? Well, I had to say that to a rather cute guy last weekend. Medical school is coming to an end. As a matter of fact, I have five more weeks to go and I’m done. And boy do I have a bad case of the Senioritis Syndrome. According to Wikipedia, one of my favorite sources of information to the (rightful) dismay of my professional superiors, senioritis is a colloquial term used to describe the decreased motivation towards studies displayed by students who are nearing the end of their schooling careers. In other words, can you get me out of here already? Therefore when a nice cute guy asks fed up girl out on a date, she gladly accepts. On we went to see Spiderman The  Musical.  To be honest, comics aren’t really my thing, and Spiderman had opened to rather unflattering critiques, but the public seemed to really love the action. Plus I’m always open to try something different, so why not? Unlike in high school when you pay $5 to go to the movies to not watch the movie, we have now grown to be mature adults who can appreciate culture.  Unfortunately I side more with the critics than the crowd on this one. The music was pretty negligible, the dancing was subpar for Broadway standards, although I must admit that watching Spiderman and the Goblin flying all over the audience was quite thrilling and brought out the child in me.  However, it seemed like it wasn’t the only thing it brought out in me as I started feeling some itching on my lower lip all of the sudden. Did a bug bite me? Am I getting a pimple? I slipped into the bathroom during intermission to find out what was going on. What I saw in the mirror was horrifying: Two or three tiny vesicles on an erythematous base right on the border of my lip. A cold sore! Otherwise known as a fever blister, or herpes labialis in the medical field. I remember I used to get them when I was a little girl, and it’s coming back to haunt me now?! Seriously? Herpes labialis is caused by herpes simplex virus type 1 (HSV-1), and typically causes blisters or sores on or around the mouth area. On the other hand, herpes simplex virus type 2 (HSV-2) usually causes genital herpes, although it is possible for HSV-1 to affect the genitalia and HSV-2 to affect the oral region as well. Herpes simplex virus is fairly common in the population, especially HSV-1.  As a matter of fact, most physicians won’t even bother testing for it. According to the College of Family Physicians of Canada, about 80% of people have been exposed to HSV-1 by adolescence, although some may never display any symptoms.  During an outbreak, the virus actively sheds from the blisters and the skin, and that’s when it is highly contagious. Once infected, the virus stays dormant in the nerve, usually retreating back to the trigeminal ganglion, and future outbreaks might be brought on by weather changes, stress, illness, or other unknown causes. Although annoying, it is a harmless condition in most healthy people, and the sores usually go away on its own in one to two weeks without intervention. There are treatment options that might speed up the healing process, though probably not by as much as one would like. Docosanol 10% cream, or Abreva, is the only FDA-approved treatment for oral-facial herpes simplex infection. It is most effective if applied right at the prodromal phase, meaning at the first tingle or burning sensation before the blisters appear, and it needs to be applied five times a day. Docosanol works by inhibiting fusion between the human cell plasma membrane and the herpes simplex virus envelope, thereby preventing viral entry into cells and subsequent viral replication. Since the compound doesn't act directly on the virus, it is less likely than antiviral drugs to produce resistance. Other studies have shown that application of zinc oxide and glycine cream every two hours while awake shorten the duration of symptoms from 6.5 days to 5 days. Studies on antiviral creams such as acyclovir or penciclovir have mixed results, and the same goes for oral antiviral treatments. The only significant improvement was seen in one old and very small study with 7 subjects published in the Lancet in 1989 showing that the anesthetic lidocaine and prilocaine creams (25 mg of each per 1 g) reduced the mean duration of subjective symptoms from 5.1 days to 2.1 days and the duration of eruption from 7.3 to 2.6 days. Bottom line is, treatment is most effective if you start early; as soon as you feel something brewing underneath and even before the first sign of a blister, and it might accelerate the healing process by a bit. As for my date, when he leaned in at the end of the night, I couldn’t help but shout: “Don’t kiss me! I think I have a cold sore.” Even though the vast majority of the population has been exposed to HSV-1, I still thought it was better to issue a warning. Well, no romantic Spiderman kiss for me! But I guess if he still calls me after that, I’ll know that he likes me for more than just my lips.       January 10, 2012 Hand Foot and Mouth Disease It is 5 in the morning, and I still have three more hours to go until the end of my night shift in the pediatric emergency department. Strangely, we haven't had a patient for almost two hours. I'm not really used to this kind of quiet. When it's busy, it's easy to operate on autopilot and just keep going. But when it's calm, that's when the fatigue starts creeping in. I don't feel so well. Mental status: slightly disoriented. Physical complaints: light-headedness, nausea, vague aches and pains everywhere. Mood: grumpy. I try to sneak a nap in an empty patient room but cannot fall asleep. Instead, I feel my heart rate increase and my breathing uneasy. What am I doing with my life? Will I match? Where will I match? (The Match is a process by which an algorithm is used to pair a residency applicant to a residency program) What if I hate it? Then I decide to transfer my attention from something over which I have no control to something more concrete. According to Freudian psychoanalytical theory, this is called "intellectualization", whereby one avoids uncomfortable emotions by focusing on facts and logic. So I start thinking about this interesting patient I saw earlier. A fifteen year-old girl came in complaining of fever and malaise for the past three days, and said that she woke up this morning with rash on her body, especially on her hands and feet. My head goes "Ding! Ding! Ding!" inside and I immediately think of "hand, foot and mouth disease (HFMD)". It is a viral syndrome, most commonly caused by one of the coxsackie viruses, resulting in the characteristic rash on the hands, feet, around the lips, and also vesicles in the mouth. How fitting given that one of the residents just complained to me that he caught it from a patient a few days ago and now feels ashamed to go to any social event due to his blemished face! Lo-and-behold, when I asked the patient to open her mouth, there were the little tell-tale white ulcers! It is satisfying to actually see something that you have until now only read about in textbooks. Luckily for the patient, this is a benign self-limiting disease. Oh wait, a new patient just walked in. Let me go jump on that! If it is another case of HFMD, I'm now an expert. After all, I've seen a case.   Hand Foot and Mouth Disease         December 22, 2011 "Comfortably Numb" From time to time, we get a patient that we almost hate. Either due to noncompliance, disruptive behavior, or maybe a personal choice with which we strongly disagree. And we all hate to admit that. JR is that  patient. For those of you who read my previous blog entry, JR is the bed-ridden gentleman with the foul-smelling ulcerated and purulent legs. Basically, they look like they are rotting, and if he doesn’t start taking care of himself, or at least allow someone to do so, they might just rot away. At first, my attending physician did not want me to enter JR’s room, because he could be aggressive and even threatening. He has been in the hospital for months, and has become quite the infamous villain among doctors, nurses, and social workers. Even his roommate complained about him and asked to be transferred to another room. After my fortunately short-lived phase of bitterness which ended as my cold dissipated, I felt I should make an extra effort to act like the compassionate doctor I want to be. Plus this JR character sort of intrigued me. So I made it my day's mission to get to know him and walked into his room as if I were visiting an old friend. I guess even the villain appreciates a friendly smile when he's feeling lonely, because JR was surprisingly pleasant and told me about his life's story while I sat next to him for two hours. So here is his story in brief as counted by the man with the rotting legs: Raised by a single mom after his heroin addict dad left the family, young JR was given his first "roofie", a sedative drug, at the age of nine by his uncle. At twelve, he was selling them at school to other kids, and used the money to buy pizza and other things that teenage boys like. Somewhere along the road as he was growing up, he was introduced to other drugs, joined a rock band, met a few girls and even got engaged. One night, on her way to see JR perform in a nightclub, JR's fiancée drove her car into a truck and died of internal hemorrhage. Too much cocaine and one glass too many before she got into her car that night. That sent JR further into a whirl of self-destruction. Cocaine, heroin (or "dope", as he calls it), percocet (a pain-killer), some adult movies... JR woke up three months later. He fell into a coma after an overdose. Maybe as another means of self-destruction, he refused all kinds of rehabilitation and stayed in bed. His bones and muscles weakened, his weight inflated and his skin started to erode. I think JR used to be handsome. I asked what shooting heroin felt like. He said like the song "Comfortably Numb" by Pink Floyd, and started singing. I asked if he could change one thing about his life, what would it be. He said he wished his mother had put him up for adoption, like she did with JR's sister. I said that I hoped he wouldn't give up on himself yet, that it is not too late. I think he secretly appreciated my encouragement. He promised me that he would try to sit up the next day. Next day, he was gone. A nursing home had finally accepted to take him.   Cooking heroin         December 15, 2011 No More to Give If a program director read this blog entry, it could potentially harm my application, but I'm not in the state of mind to care... We round. Room after room, patient after patient. They all look the same after a while. Overweight, unkempt. That’s what it is like in the South Bronx. Half of them don't speak English so I stand there, listening to my Ecuadorian attending physician singsong in Spanish to those patients. It sounds pretty, but I'm too dazed to try to understand. I used to get excited whenever we had a Hispanic patient because I got to practice my Spanish. This lady was sitting with her back facing the door, breathing heavily into her nebulizer mask which serves to administer asthma or COPD (chronic obstructive pulmonary disease) medication in the form of an inhaled mist into her lungs. All I could see from the door was her round habitus. I wonder if she’s able to walk at all with all that weight. And there is that hacking cough, a cruel testimonial to her years of smoking... It’s not our job to judge, everyone has a story. We’re here to heal. My team is moving on to the next patient. I trail along, dragging my feet under a veil of haziness, my head heavy and pounding, my nose leaking, and my mind dreaming about my bed. I wonder if I have “mono”? That’s mononucleosis, also known as the kissing disease because people, especially teenagers, commonly catch the Epstein-Barr Virus while kissing. Then come the sore throat, swollen lymph nodes, and insurmountable fatigue. My symptoms don’t really fit with mono, but I am so tired. Then I get a whiff of this putrid smell that jolts me awake for a few seconds. It’s our next patient, a young man in his late 30’s, both legs seem to be decomposing with horrendous ulcers as a result of venous insufficiency. It means that his legs have not been getting adequate blood circulation because he has been bed-bound for months. Something about overdosing on multiple drugs and then ending up in the Medical Intensive Care Unit with a tracheostomy. He’s defiant, abusive of social services, and refuses treatment. Oh, what’s the point? It’s those who don’t want help who need help the most. That used to be my motto. It gets tough keeping that motto when you work in the South Bronx, where a significant portion of patients don’t care much about their health or just don’t know better. I guess I could sit down with some of these patients and try to get through to them, and I have done so in the past. I talked to them, listened, tried to understand from their point of view why it was so difficult to keep a healthier lifestyle (stop smoking, drinking, walk more, eat less, stop shooting drugs, use a condom…). But it’s mentally exhausting, and I feel like I don’t have any more compassion to give. Now my intern wants me to go fax stuff for her. I could mention that I didn’t go to med school to become a secretary. And then I stop and think to myself, why did I go? I remember…to help people. To care. To show compassion. Even in the face of adversity. I fax the papers. Then I decide to go back to the poor soul with the ulcerous legs to see if I can offer some sort of comfort. Maybe something will get through. I’m not even a real doctor yet, am I jaded already? Maybe tomorrow will be a better day…     December 8, 2011 Homeless and Jobless Being a fourth-year medical student sometimes feels like being a vagabond. In the past four months, I have moved four times, living out of my suitcase, traveling from hospital to hospital to do different elective rotations. After my one month at the Montreal Jewish General Hospital in Emergency Medicine, I moved down to Florida for a month to rotate at the Cleveland Clinic in a suburban city called Weston where houses are big and the air is fresh. Now I am back to New York city, where apartments are miniature but the air bustling with life. It was not after over a month of search on Craigslist and numerous visits to apartments all over the city that I finally found a pied-a-terre on the Upper East Side for an arm and a leg. After seeing grimy bathrooms, potential roommates who looked like heroin addicts, and less expensive apartments in shady neighborhoods, I decided that it was better to dish out some extra dough in exchange for feeling safe and comfortable. Luckily, while I was homeless, a friend was kind enough to offer me shelter. Thinking initially that it would only take me days to find something of my own, I stayed there for so long that I was starting to feel like a piece of furniture in his living room. Now that I finally have a place of my own, my stress level has significantly gone down. My cortisol (a stress hormone) level had been on a constant high, being homeless and jobless. Yes, I am at last almost finished with medical school, and it is time to apply for a real doctor's job - in other words - residency. A few thousands of dollars later spent in licensing exams and residency applications, I am now in the process of interviewing. More traveling, suits, heels, smiles, and shaking hands. Very tiring. But I am thankful for the programs that have decided to give me a chance to impress them, and hopefully, in a few months, I will have both a home and a job.   Me circa 2009 - 2010, experiencing what being homeless feels like. Just for one day.         October 10, 2011 Lincoln vs. McGill Part II - Getting My Hands Dirty One of my first patients at the Montreal Jewish General Hosptial Emergency Department (JGH ED) was a lovely 90 year-old lady who came with complaints of epigastric discomfort. She told me that I was going to make the best doctor. Obviously, she quickly became my favorite patient. She had been having burning pain in the mid-lower part of her chest for 2 days, and aside from some mild nausea, she denied any other symptoms. No diaphoresis (profuse perspiration), no pain elsewhere, no numbness, no dizziness. After taking her history and examining her, I somewhat dismissed her symptoms as heartburn in my mind. But because of her age and cardiac history, I still ordered a full cardiac workup which includes an electrocardiogram, a chest x-ray, and blood work with cardiac enzymes just to be sure. After all, women and the elderly often present with vague and atypical symptoms when having a heart attack. We gave her some medications for her nausea, and I moved on to other patients. I had not forgotten about her, however. In the midst of constant inflow of patients, I went back to check up on her. She said she was okay, but still a bit nauseous. Her cardiac lab results came back and showed an elevated cardiac troponin level, sign of damage to the heart, such as a heart attack. What I thought was heartburn turned out to be something much more serious. I told the nurse to give her some more anti-nausea medication and we also started her on Lovenox, an anticoagulant. The idea was to prevent further ischemia (restricted blood supply) to the heart. After everything was done as per protocol, I returned to the marathon of the Emergency Room. All of the sudden, I noticed some commotion in the Resuscitation Room. Curious about the action, I went to take a look, and realized that the patient being resuscitated was my old lady! Despite our treatment, her heart went into ventricular fibrillation (a type of lethal abnormal rhythm of the heart). Someone was giving her chest compressions. When that person got tired, I immediately took over. Somehow, I felt that it was my responsibility to take care of this lady. As I was compressing her chest, probably cracking a few ribs in the process (you really do have to press hard), I could make out from the corner of my eyes that people were staring at me, but didn't give it much thought. Eventually, after chest compressions, electrical shocks and anti-arrhythmic drugs, the patient regained somewhat of a regular heartbeat, and Cardiology was called down. That was when the first person who was performing chest compressions on my patient approached me. He was an orderly. "Do you always do chest compression?" He asked. What a bizarre question... No, I do not always do chest compressions, only when someone is coding in front of me and chest compressions are indicated. The orderly explained to me that he was surprised because he had never seen medical students perform chest compressions, not even the residents do them. That's what the orderlies are there for. How interesting! I later learned that, compared to my previous experiences where I often had to get my hands dirty, the medical professionals are less hands-on but more academic in this institution. I'm not sure if it is just this hospital, if it is McGill or if it's the Canadian way of things. Not one is better than the other, just different. As for my lovely old lady, she survived the night but remained unconscious. I went to visit her in the CCU (Coronary Care Unit), a ward specialized in taking care of patients with heart attacks and other cardiac ailments. She looked frail, and even though we had done everything right, she was probably never going to wake up again.   Montreal Jewish General Hospital Emergency Department Entrance   Oct 5, 2011 Lincoln vs. McGIll Part I - A Rotation Back in Canada Years after being rejected by McGill University Medical School (to this day it still stings, and I would like to lick my own wounds by mentioning that I was at least interviewed and waitlisted), I thought it would be interesting to come back to my Alma Mater and my hometown to do an elective. St. George's University allows us to schedule up to 12 weeks of rotation at out-of-network hospitals, meaning at hospitals that are not affiliated with our school. Students can use that opportunity to experience medical education from another university or even another country. After a lot of headaches and paperwork, I managed to secure one month of Emergency Medicine elective at the Montreal Jewish General Hospital (JGH), a McGill University Hospital. I could not find the data online, but I was told by one of the attendings that the JGH Emergency Department (ED) is the second busiest Emergency Rooms in the country, after University of British Columbia. That is interesting, because I had just finished a rotation at the Lincoln Hospital's ED in the South Bronx, the second busiest ED in the country as well, following UCLA. How does health care compare in the US and in Canada, at least as far as Emergency Medicine is concerned? Would I receive a different type of education at a community hospital, which is what Lincoln is, and at a University hospital such as the JGH? And obviously, Montreal and the Bronx are two very different cities which means different patient population or clientele at the hospital. We are about to find out...   Montreal Jewish General Hospital         Oct 4, 2011 Score Report Week after week I waited, and nothing. I was told that if would take three weeks to receive the results of our USMLE Step 2 CK (the second part of the United States Medical Licensing Exam) exam which I took this August, after spending the summer studying, forfeiting almost all outings with my friends.  But due to new question formats, it was taking longer than usual for results to be released. The exam was a 9-hour ordeal and I could not even gauge whether I did well or not, and even wondered at some point whether I had passed or not. Residency applications started, I started a new rotation, and I almost forgot about it until a few days ago I received an email notifying me that the score report was ready. I was actually in our OSS office when I clicked on the score report as I pretended to pay attention to what Dr. Joe was saying. The first word I saw was “PASS.” Phew. At least I won’t have to go through that again. Then I scrolled down the screen little by little to find my score, scared of what I would see. Next came a scream that startled the entire office. I could not contain my emotions. Let’s just say that I was very pleasantly, no, ecstatically surprised! This sure gives me an extra boost of confidence for this residency application season. Now let’s hope that interview offers start rolling in!   August 19, 2011 Choosing a Specialty Choosing to go to Medical School was an easy decision. It was as if medicine had chosen me, I felt like I was meant to be a doctor. I loved the knowledge, and wanted nothing more than to use that knowledge to do some good. Getting accepted to Medical School was not a smooth ride for me, however. After being rejected and waitlisted by home universities, I decided to go abroad to pursue my dreams. Now that “someday” is around the corner, and I am faced with some difficult, possibly life-changing decisions. I spent the past year doing my clinical rotations in New York, had a taste of several different specialties, yet have never been and will never be exposed to some others. The third year of medical school is dedicated to rotating through “core specialties”, which are Internal Medicine, Pediatrics, Obstetrics and Gynecology (OBGYN), Surgery, and Psychiatry. Only in fourth year can one sign up for “electives” and venture into other areas of medicine, such as Dermatology, Radiology, Plastic Surgery, and many more. After I had completed my last rotation as a third-year student, I dove right back in and started my first fourth year elective the following week (we get to make our own schedule in fourth year, to a certain extent). I didn’t want to waste any time because Residency Applications were coming up, and all the medical students, including myself, were scrambling and hoping to get glowing Letters of Recommendation, ideally from the specialty that we want to pursue. So someone who wants to do Radiology, for example, needs to hurry to secure a rotation in that department before the autumn season of our fourth and last year of medical school, because that is when our applications need to be submitted. Residency application season is an exciting time. We will finally become doctors and do what we love. My friend who loves OBGYN is relieved that she will never have to deal with elderly patients with multiple co-morbidities and taking fifteen different pills again. Another friend who is an aspiring psychiatrist hopes that he won’t have to see blood for the rest of his career, and can instead study the intricacies of the human mind. I, on the other hand, look at residency applications with more apprehension than excitement. I do not feel quite ready yet to commit to a single specialty for the rest of my life. Looking back, I enjoyed most of my third year rotations, granted some more than others, but I always took pleasure in learning different things. The organized chaos of the Emergency Department and the need to think fast and act quickly bring me an indescribable exhilaration. On the other hand, taking the time to dissect and analyze a problem and finally solve a medical puzzle like internists do also provide me great satisfaction and feed my inquisitive mind. Then there is the family physician who is the all-emcompassing doctor, taking care of the young and old and develops life-long relationships with her patients. So how does one choose the perfect specialty? Take on-line quizzes? Make pros and cons tables? Talk to people who work in the field? Yes, I have done all that. But it looks like I have some more soul-searching to do.       June 10, 2011 A Day in the Lincoln Emergency Room “I've been shot! I've been shot!” The man in Resuscitation Room 1 shouted with panic and disbelief. Covered in blood, this thirty or so year-old man was surrounded by nurses, residents, attendings - all scurrying around doing different things – and me, the medical student, witnessing her first gunshot wound (GSW) victim the fourth day of her Emergency Medicine rotation. I had been waiting for this moment ever since I started my clinical clerkship at the Lincoln Medical and Mental Health Center, a Trauma One center in the South Bronx. It was three o'clock in the morning, and I had never felt so awake and alive. Trying to be useful, I gingerly squeezed in between the health care team, started an IV line on the patient, and ran to fetch for instruments as the attending physician yelled out orders. Bags of saline, Foley catheter, intubation tray, it felt as if I were in a relay race, running for this patient's life. The focus, sense of urgency and, paradoxically, of calm, were feelings that I had never experienced in any other rotation. Aside from the IVs on his arms, two femoral lines were placed, each line connected to three bags of saline free flowing into his body to compensate for fluid depletion from massive blood loss. He had three GSWs that we knew of: one on the left arm, one in the left thorax and one in his left cheek. The surgical trauma team arrived within minutes and creatively placed three Foley catheters, tubes normally inserted into the bladder to drain urine, into the big gap in his cheek, and inflated the catheters to create a tamponade to stop the bleeding. Patient was sedated, intubated, vital signs seemed stable… our job was done. The rest will be taken care of by the surgeons. I went back to my station, sat down to digest what had just happened. I felt… amazed, exhilarated, high. But in Lincoln ER, there is no time to sit around and ponder. With no pause, everyone left the Resuscitation Room and went about to their business. Other patients await.   The Aftermath, taken from http://www.lincolnemresidency.com       May 30, 2011 I'm a Fourth Year Now Do you remember the Huggies Pull Up commercial from the 90s where the proud toddler with his new diaper sings: "Mommy wow! I'm a big kid now!" Well, I want to sing "I'm a fourth year now!" Can you believe that it's been a year? I mean a year since I started my clerkship. Exactly one year ago I put on my brand new short white coat and showed up at Lincoln Hospital in the South Bronx for my Internal Medicine rotation, not knowing what to expect. I was excited, scared, and most of all, completely lost. I distinctly remember feeling like I was running around the hospital like a headless chicken, skipping lunch on some days because I was so excited and so keen. Now when I look back on how eager I was I just want to laugh. I still skip lunch on occasions due to the high patient volume that we have to take care of but I have learned to also take care of myself. Always keep some snack in your pocket or locker. Sit when you can sit; eat when you can eat; sleep when you can sleep; and go to the bathroom when you can sneak away for a few minutes. Obviously some rotations are more easy-going than others, but the past few months have tested both my physical and mental limits. Surgery at Woodhull Hospital in Brooklyn was… hardcore. I got up at 4:30 AM to go to work and got home on average at 7 PM. On top of that, we were on 24-hour calls every four days, and the calls usually end up being 27 hours rather than 24. That's when comfortable shoes are absolutely crucial. Standing in the OR (Operating Room) for an eight-hour long hemicolectomy (resection of half of the colon) will make you feel like you're about to break. Oh, another important thing about shoes is good airing. Standing that long and running around all day does not bode well for odors. I have so much respect for the surgical residents that I worked with. As much as I busted my gluteus during that rotation, the residents worked twice as hard as the students did. My resident was kind enough to let me sleep a few hours whenever we were on call while she stayed up all night admitting patients from the Emergency Room or taking consults from other departments, and still stayed sharp in the morning. Not only was that rotation demanding, it opened my eyes to a whole new patient population and array of diseases. Abscesses gushing with pus galore and wounds infected beyond imagination! A little gross, but very very cool. At least I thought so! Surgery ended with lots of backache, sore calves, one Achille's tendonitis, lots of new knowledge and funny stories. I rewarded myself with a spa massage and jumped right back to a rotation in Emergency Medicine as a fourth year medical student. So far I'm loving it, but can definitely feel the fatigue creeping up. Like I said before, sleep when you can sleep, so so long readers, I'm headed to bed so I can be ready for another 12-hour shift tomorrow in the second busiest Emergency Room of the country!   Ready to scrub in on an orthopedic case: Hip replacement     April 15, 2011 Why Do Doctors Want to Be Doctors? It started off as a random rant on Facebook right after I found out that my best friends from home are going onvacation to St. Barts and I am yet again, left behind, because I cannot take time off from medical school. Last year, they all went to Mexico to some fancy villa because one of the girls works for a luxury retreat company and got a good deal on a vacation home. I had to study for my pathophysiology exam. This time, I’m rotating through Urology, a branch of medicine that deals with disorders of the urogenital system. In this specialty, a very competitive one at that (you will see why I’m making a point to underline how difficult it is to match into Urology), we most commonly see men with prostatic problems, namely prostate enlargement which causes urinary difficulties, something all men will encounter as they age, cancer of the prostate, bladder, genitalia, and more. One of the physical exams frequently performed in Urology is the Digital Rectal Exam (DRE), whereby doctors insert one finger into patient’s rectum to feel for masses, size and irregularities of the prostate, and check for presence of blood, which could be sign of something benign such as hemorrhoids, or something more serious like colon cancer. Let me stress one thing: Unless you are a radiologist or a pathologist who never has to deal with patients, medicine is often dirty, smelly, messy, and sometimes patients can be ungrateful, rude, and frustrating. That’s the real life of a doctor. So after finding out about my friends’ escapade sans moi, I updated my status on Facebook, comparing my friends’ glamorous life exploring different parts of the world to mine exploring different human orifices in the hospital. My satire-tinted status update generated much online laughter and well-humored sympathy, which was the goal of my comment. Until one first-year medical student who just started medical school asked me: “You have to do that? I thought med students could get nurses or PAs (Physician Assistants) to do that stuff for them. I think I'm going to be sick.” I was mildly put off by this student’s mentality that nurses or physician assistants are doctors’ minions who are there to do our dirty work, but chalked it off to a junior’s ignorance, and patiently explained to him that, no, doctors and medical students perform DREs because we are the ones who have to make the diagnoses. Junior Med Student then replied: “I was afraid you'd say that. How many times (per day) are we talking about, on average? I know it depends on the rotation, but you make it sound like you're doing it every day. Either way, I feel for ya. All the more reason to stay the hell out of Family Med.” That really riled me up. But I thought, maybe I can help this junior see things in a different light, hence my response: “While I like to complain and exaggerate for comical purposes, Digital Rectal Examination is really not that bad. It is not the most pleasant thing to do, but it is even more uncomfortable and embarrassing for the patient. Medicine in general is nasty and there are things that are far grosser than DRE. Also, FM docs are not the only ones performing DREs. Internal med, emergency med, surgery, obgyn, urology, GI, etc. I hope you don't have the misconception that being a doctor is all glamorous and prestigious. It is not. It's hard and dirty work. The only "glam" thing about being a doctor is the privilege you get to be part of a patient's life while he or she is in the most vulnerable state, and to contribute to his or her feeling better.” I was pretty satisfied with my retort, and was hoping that I had helped this junior med student be more compassionate. Well, he answered that he did not endure $200,000 in debt and incredible sacrifice just so he could touch dirty and unworthy people who contract diseases due to their own indiscretion and then “expect a poor med student/ doctor to just make everything right again.” According to this student, only International Medical Graduates with low board scores have to resort to performing demeaning acts such as DREs because they can only go into Primary Care specialties such as Family, Internal or Emergency Medicine; and that is why “cleaner” specialties such as Dermatology and Plastic Surgery are so difficult to get into. At that point I gave up. There is no point in arguing. His ignorance and arrogance sickened me much more than any bodily fluids I might have to deal with at the hospital. Moreover, I wonder if he knows that Urology and GI (gastroenterology) are some of the most competitive specialties. Surgery and Emergency Medicine are also very challenging. Although internal medicine is the most popular specialty in the U.S., it certainly is not a piece of cake, with many program directors demanding a Step 1 score in the 90’s. And while the old-school and out-of-date mentality that Family Medicine is only for those who could not get into any other specialty, this specialty becoming more and more popular, especially with the advent of socialized medicine in the U.S., and I dare challenge anyone who has a broader base of knowledge than a family physician, who received training not only in adult and pediatric medicine, but also in surgery, obstetrics, preventive and critical care. The saddest part is that more than a few medical students and doctors have the same attitude. So it got me thinking. Why do doctors want to be doctors?             March 26, 2011 Intubate - Success! It was one of those moments that gets indelibly etched in your mind.  Your very first time. I mean intubation.  For me it happened in the ER (Emergency Room) of Lincoln Hospital in the South Bronx. A patient with history of alcoholism came in with pending respiratory failure. The signs were subtle, but certain. In fact, they were so subtle that I had completely missed them, but the resident under whom I was working spotted them immediately: The patient was mildly short of breath, and was contracting his intercostal and platysmal muscles to breathe. (OK, so I’m just showing off my limited knowledge of anatomy a little) Patients showing such signs can deteriorate very rapidly, so the team decided to intubate.  This is a procedure whereby the physician inserts a flexible tube down the patient’s trachea (windpipe) to secure an open airway. Sedatives were administered. Followed by numbing agents. (They actually allowed me to do that.) Then the medical resident proceeded to intubate. Failed. Tried again. Failed. Attending physician took over. Failed. Emergency physician tried his hand. Failed. The anesthesiologist, the recognized expert at intubations, was paged. He came.  He saw. He failed to conquer. Panic all around. Apparently the patient was having laryngeal spasms and his airway had closed up. The oxygen level on the monitor was dropping quickly, people were running everywhere, the anesthesiologist was yelling. I was trying to be useful but the best I could do was to stay out of the way.  Eventually a decision was made to perform an emergency cricothyrotomy: An incision was made directly in the patient’s neck to access his airway and a tube was inserted into his trachea via the incision to ventilate him artificially. Although I had done nothing, I felt high from the excitement.  And I also learned something.  Intubations can be very tricky! I looked forward to the day, albeit with some trepidation, when I would take a more active role. And that day was yesterday! Nearing the end of my 3rd year of medical school, I successfully intubated a patient! Maybe it was beginner’s luck, but that tube slid down as smoothly as depicted in all those educational videos I had watched. I opened the patient’s mouth, guided in the laryngoscope, a piece of equipment designed to displace the tongue for a better view of the larynx (voicebox), saw the vocal cords and the trachea, and then held my breath as I pushed on the endotracheal tube. Vapor in the tube was proof that it did indeed go into the airway and not into the esophagus, a common mistake made by rookie intubators. Phew! It’s hard to describe the satisfaction (and relief) I felt. Not so long ago I hadn’t been able. to recognize the crucial signs of pending respiratory failure. I stood by feeling helpless as I witnessed a very difficult attempt at intubation and an emergency cricothyrotomy. But that was then. This is now. Here I am, having just performed my first ever intubation! Exhiliration! Moments like these make all my missed vacations and long nights of struggling with anatomy worthwhile. I’m finally beginning to feel like a doctor. Endotracheal intubation     February 2, 2011 Sick Again I don’t think I have been totally healthy ever since I started my clerkship. It’s always something. Strep throat, chronic cough, bad cold, GERD (gastro-esophageal reflux disease) exacerbated by stress and coffee.  Right now I’m crawling back and forth between my bed and the toilet due to gastroenteritis that I probably picked up from a kid in the Emergency Room (ER). Parents: Don’t bring your child to the ER because she or he has been vomiting and/or having diarrhea for the past few hours. There’s a virus going around, perhaps it is the norovirus, or the adenovirus, or the rotavirus. In any case, there is nothing we can do; just keep the kid hydrated with Gatorade, and leave your germs at home!  One of my patients in the Emergency Department was a 12 year-old boy brought in by his mother because he had been vomiting and having the runs for the past 15 hours. His mother and sister had the exact same symptoms a few days ago and were told by their physicians that they had gastroenteritis, otherwise known as the “stomach flu”, and that it would go away on its own, which it did. Why this mom brought her otherwise healthy son into the ER for this non-emergency illness is beyond me, and it had a direct consequence of making my attending physician curse for fifteen straight minutes (ER docs are not really known for their finesse…). Anyways, after I interviewed the mom and the kid, did a focused physical examination on our patient, I made sure to wash and sterilize my hands and at the same time told my resident: “I really don’t want to get gastro. Last time I had gastro, it lasted for a week.” Well, that same evening, my stomach started feeling funny. I thought maybe I had had too much coffee and not enough food. But oh no. It was not just my usual heartburn. A few minutes later I had jets shooting out from above and below. People, if you are experiencing the following symptoms: abdominal cramps, vomiting, diarrhea, and have had contact with someone with similar symptoms, you probably have a case of gastroenteritis, which is inflammation of the gastrointestinal tract. The disease is self-limiting, usually lasting one to three days, and does not need medical attention unless you are immunocompromised (for example the very young or the very old) or have other comordibities (e.g. diabetes). Just make sure that you are well hydrated. And while studies show conflicting results, my mom swears that ginger ale is good for nausea. You might also give that a try. If your body doesn’t like it, it’ll come right out.     December 5, 2010 Oh Canada! It’s been a while since my last update. I have been extremely tired; after spending all day in front of the computer – because we have to document everything we do for a patient – when I come home I really don’t want to keep staring at my monitor and typing. I just finished six weeks of rotation in Pediatrics (Peds) and now I’m in Psychiatry. I loved the kids in Peds, love them from babies to teenagers. And people working in Peds are generally extremely nice and friendly. They say that Pediatricians are a difference race, I guess that’s true. It’s funny that doctors from the same specialty exhibit the same characteristic personality traits. Pediatricians are mellow and gentle; obstetricians are boisterous and fight with each other but forget about it two minutes later and become best friends again; psychiatrists are calm and quirky with a unique sense of humor. I wonder where I fit in best. I also wonder which geographical area I fit in best. Alas, I’m already half way through my third year of med school and it is time to think about residency applications! I have always thought that a combination of Family and Emergency Medicine would be perfect for me. And after some clinical experience, I am even more convinced of my first intuition. I enjoy diversity and seeing a broad range of illnesses; I like patients of all ages; and I also take great pleasure in building relationships with my patients and educating them about disease prevention and management. On the other hand, I also love the fast-pace and the pressure in the Emergency Room. Crises don’t make me panic, they help me focus, and I have got to admit that I am bit of an adrenaline junkie. Therefore, a two-year residency program in Family Medicine followed by a one-year fellowship in Emergency Medicine seems perfect for me, and this program is offered by all universities in Canada. After some research, however, I found out, to my disappointment, that going back to Canada will probably not be an option for me. According to the CaRMS (Canadian Residency Matching Service) website, a mere total of 105 positions are offered in Family Medicine in the first iteration in the whole country for International Medical Graduates (IMGs) like myself https://w1c.e-carms.ca/pdws/jsp/pd.do?d=919&p=p3&m=1. Most of those positions are offered in Ontario, none in Quebec. So despite my being perfectly bilingual (as a matter of fact, I speak fluent English, French, Mandarin, and can get by in Spanish and Taiwanese), Quebec will not be benefiting from my service. How about Ontario? Well, the province requires a Return of Service of 5 years in an underserved area after you finish your residency. Do I want to get stuck in some frozen village where it’s -20C half of the year for 5 years? I think not. So maybe I’ll just stay in the big U. S. of A. I don’t know if I can practice Emergency Medicine as a Family Physician here in the U.S., but I’ll probably be better paid and lesser taxed. Unfortunately, being a non-American citizen, I will have to face visa issues which I still do not have a good understanding off. In laymen terms, I’m screwed. I spent my first American Thanksgiving with another Canadian expat eating turkey in a restaurant with other people who I assume are also expats of some sort (or loners who don’t have families?) Will I remain an expat forever? I guess we shall see.     October 4, 2010 From Mommy to Baby Warning: The following content might be too graphic for some. My Ob/Gyn rotation finished with a bang. Two bangs actually. At the end my six-week rotation, I had coached women in labour on how to push, when to push, measured how dilated their cervix was with my fingers, looked at fetal heart rate monitors to make sure that the baby inside mom’s uterus is doing fine. Finally, on my last day, I got to deliver two babies all by myself! My first baby came really fast. I had just measured mom’s cervix, which is the neck or bottom part of the uterus, and it was not completely dilated yet. A fully dilated cervix measures 10 cm, estimated by the examiner’s second and third finger, and that’s when the birth canal is big enough for the mom to push the baby out safely. The nurse, who had about 10 years of experience in delivering babies, told me, however, that this baby could come out anytime, because although the top part of the cervix was not fully dilated, you could already feel the head of the baby at the bottom. I nodded as I took in her wisdom with fascination. Next thing I knew, both the attending doctor and the nurse had stepped out of the room, I was all by myself, and as I turned my head to look at the patient, I see a head coming out of her vagina! This was not supposed to happen, not yet! The bed was not prepped, the stirrups were not placed, but the baby was coming. I shouted towards the door “The head is here! The head is here!” then quickly gowned and gloved up, and started doing what I had seen residents and doctors do. I stood between mom’s legs, put one finger at the top of the vaginal opening to protect the urethra from tearing, and applied gentle pressure at the bottom the vagina. At this point, a bunch of people had run in. I had the attending at my left and the resident at my right, watching and supervising every single move I made. With their instructions, I held the baby’s head when it was completely out, checked for the cord around the neck which in this case there wasn’t, helped the baby turn to the side, and watched as the baby’s shoulders, arms, and the rest of the body came out to this world. I told mom that it was a girl and she cried of joy and relief. I smiled, too. Although I did not always love my Ob/Gyn rotation, that was pretty amazing, I must say. After the baby was born, I delivered the placenta, and sutured mom’s minor vaginal tear with my attending’s help. Later that day, I delivered another baby. Both deliveries were very smooth. And it is quite incredible how automatic the birthing process is when it is a normal spontaneous vaginal delivery with no complications. The baby basically comes out on its own and all the doctor has to do is to catch it. After all, women have been giving birth since the beginning of time, with or without help. But I still think it is one of the most traumatic things a woman has to go through. All that stretching, expanding, tearing, rupturing, bleeding… Yikes! Well, now I’m starting a new rotation in Pediatrics. Let’s see what happens after a baby makes it out of mommy’s womb!   September 9, 2010 The Girl in Room 2 I met her during my first overnight call. I had started the day at 6 A. M. in Ob/Gyn (Obstetrics and Gynecology), my current rotation. I was to stay at the hospital and work for 24 hours! Again, as I stated in my previous entry, “work” is more of an aggrandizement; I basically follow the residents around and try not to get in their way, and maybe even attempt to help them from time to time. After mucho coffee to pump myself up for a whole night of screaming women and crying babies, I started rounding (going from room to room to interview and examine each individual patients) with one of the doctors on call that night. “Go check out Room #2,” the doctor told me. “But be careful,” he added “don’t go in and say ‘Congratulations’, it’s a fetal demise.” That means that the fetus, or the baby, died in mom’s uterus before being born. With that piece of information, and with much trepidation, I entered Room #2, having absolutely no idea what I was going to say to the patient. She was a remarkably beautiful young Hispanic woman; 16 years old but looked even younger than her age. Her body was petite except for her full-term belly. When the anesthesiologist came, she slowly picked up her long dark hair for him to place an epidural – a point of access for later anesthetic administration – in her back. I was mesmerized by how young, how beautiful, and how calm she was. Actually, calm isn’t quite the correct description, it looked more like the kind of indifference that you can only find in adolescents. With her were her mother and boyfriend. The boyfriend was probably no more than 18, also small in size, tear-drop tattoo and a look of anguish on his face. I asked her how she was feeling; she said that she still had pain and that the epidural wasn’t really working. If she was suffering, it definitely did not show. Some time later, she went into active labour. I helped position her legs, held her hand as she pushed the baby out without emitting a single grunt, cry, or sound. One would have thought that it was a planned silent birth. Only when the doctor put the expired baby who, aside from being grayish in color, looked almost normal, did she allow herself to cry for a fleeting moment. Her momentary vulnerability made her look even more childish, and I couldn’t help but wish I could hold her in my arms. Then, the nurse took the baby away to be examined by the pediatrician while the boyfriend stared at it as if in disbelief and the grandmother sobbed quietly. I also stared at the baby. He had died that same morning, and appeared like a regular sleeping baby. Except that he was not. While everyone’s attention was geared towards the baby, the work was, however, not over for the girl in Room 2. She lay there, legs spread wide open, naked body exposed, blood still streaming down from her vagina. She still had to push the placenta out. When it was all done, she asked for some cold water. I immediately ran out to get her some, since not possessing any actual obstetrics skill, that was pretty much the only thing I was capable of doing to help her. To my surprise, her deadpan face broke into a big blossoming smile as she thanked me for the water. She later thanked me three more times that night. I don’t know what I did to deserve that... I went home that night very pensive. As sad as the situation was, the demise of the baby was probably a second chance for the girl in Room 2. After all, what was a sixteen year-old going to do with a baby? When I went to work the following day, she was already gone. I figured she must have been discharged. But a few days later someone informed me that she required emergency surgery the next day due to uncontrolled bleeding. That can happen when the placenta has not been completely expelled and fragments remain in the uterus. I don’t know if that was what happened to her, nor do I know if all turned out fine since I do not have her medical chart number. Girl in Room 2, I hope you are well. And I hope that you take this second chance at childhood to grow into a happy and fulfilled woman.         August 5, 2010 At Least I'm in the Picture! According to the World Health Organization (WHO), 15 million people are affected every year, of these, 5 million die, and another 5 million are permanently damaged. It is the third leading cause of death in the U.S., with over half of the afflicted individuals being women. Most tragic of all, the majority of these cases are preventable. Although merely in the fetal stage of my medical career, I have already witnessed more than a handful. Strokes, that is; otherwise known as cerebrovascular accidents, or CVA. A stroke is when there is interruption of blood supply to an area of the brain, either due to blockage of an artery, in which case the stroke is said to be “ischemic”, or when there is leakage of a blood vessel, which is what we call a “hemorrhagic” stroke. When either of these two scenarios happens, brain cells start to die from the lack of blood hence oxygen supply, and brain damage occurs. What happens after a stroke depends largely on the extent, the location, and duration blood shortage. Prompt and adequate intervention is of utmost importance. Having rotated for nearly a month in the Medical Intensive Care Unit (MICU) of the Lincoln Medical Center in Bronx, NY, I have been able to observe and participate in CVA management with our Stroke Team on a few occasions. Whenever the Emergency Department (ED) receives a patient with symptoms suggestive of a stroke, such as slurred speech, unilateral (one-sided) weakness or numbness, decreased sensation on one side of the body or face, just to name a few, the Stroke Team, which consists of a group of designated physicians who are trained to manage a stoke, is “activated.” What that means is that a group of doctors scurry to the patient in question to evaluate, assess, and treat the latter in the timeliest fashion. Sometimes, a train of eager medical students such as myself tags along for the action. First thing to do is to evaluate and document the patient’s NIHSS (National Institute of Heath Stroke Scale) within 15 minutes of arrival to ED or discovery of symptoms. The NIHSS is a standardized method used by physicians to assess the level of impairment. It evaluates the patient’s mental status, sensory, motor, and verbal capacities. A score of 0 means that the patient does not have a stroke; score 1 to 4 indicates a minor stroke; score 5 to 15 indicates a moderate stroke; score 15 to  20 indicates a moderate to severe stroke; and score 21 to 42 indicates a severe stroke. Depending on where on the scale the patient has scored, treatment options and prognosis may vary. Moreover, a patient suspected of having a stroke automatically gets a brain CT, a scan that allows the medical team to visualize whether the patient has any ischemia or hemorrhage. Some patients qualify for thrombolytic therapy, which means that a substance capable of breaking down blood clots such as tissue plasminogen activator (tPA) is injected into the patient’s arterial system, in hopes of dissolving the obstruction that caused the stroke. Unfortunately, tPA is not without risk, which is why elderly patients and stroke patients who have waited too long (over 3 to 4.5 hrs depending on hospital guidelines) to seek medical attention do not qualify for tPA treatment for fear of massive bleeding, which itself could cause much more damage than the stroke itself. On the other hand, I have seen a stroke patient who, after prompt initiation of thrombolytic therapy, recovered fully and was up and about the very next day. For those who are not so lucky, only supportive care can be offered. We counsel the patients on lifestyle modifications, such as low fat diet, regular exercise, smoking cessation, all of which are significant risk factors of stroke and many other diseases. Patients who are left with permanent motor or sensory impairment are referred to rehabilitation to try to regain function, although a 100% recovery is rare. One early morning, as we all tried to fight our sleepiness, we were surprised by a beautiful display of food in the residents’ lounge of the MICU. Us poor medical students and residents always get so easily excited about free food; but we were at the same time wary of this unusual treat in the notoriously somber MICU. It turns out that the director of the unit, Dr. R. Loganathan, was in a particularly good mood that day. The department had just been awarded the Silver Plus Performance Achievement Award by the American Heart Association/American Stroke Association in recognition of its superior management of strokes. I knew that Dr. Loganathan wouldn’t be so nice to us for nothing. Congratulations!   Some members of the Lincoln Medical Center's Medical Intensive Care Unit team in July 2010.       July 14, 2010 Fatigue + Arrogance + Frustration = Dangerous Combo Two months into my clerkship and I thought that I had already become an expert phlebotomist. So when the resident in MICU (Medicine Intensive Care Unit) asked if I needed help drawing blood from a patient, I nonchalantly said no. After all, I had done it several times before. The resident was happy that she didn’t have to babysit me, and I was secretly pleased that she trusted me enough to do it by myself. Well, it turns out that I’m just a cocky medical student, moreover I found out that fatigue + arrogance + frustration is a dangerous combo. The patient in question was an older gentleman, African-American, very much overweight, and with absolutely no visible veins. Old age, dark skin and obesity are three big hindrances to finding a vein. And when we can’t find a vein, one alternative is to take blood from an artery, such as the radial artery at the wrist. You find the radial pulse with your fingers and carefully puncture exactly where the pulse is felt. This is also done when arterial blood gas (ABG) needs to be performed in order to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. ABGs are more challenging than regular venous blood draw because it is not always easy to hit the exact right spot, and also, it is notoriously painful. Being the curious cat that I am, I asked to have ABGs done on myself on my second week of clerkship so I could feel for myself just how painful it is. I didn’t understand how a simple blood draw could cause so much agony, and I figured that once I’ve experienced it, it would be easier for me to relate to patients when I have to do it to them. None of the residents whom I asked would perform the ABG on me, except for my first resident, Dr. Carlos Rodriguez, who either wanted to foster my sense of empathy, or merely jumped on the opportunity to torture a med student. He must be pretty skilled though because I barely felt a thing the first time with the smaller needle, and with the larger needle the second time on the other wrist, I only felt some soreness, probably because a nerve was closeby. After that little experiment, I did ABGs on a few patients, who told me, to my great satisfaction, that “it wasn’t too bad.” Until yesterday. Back to the older, African-American, overweight patient in MICU. I had already taken his arterial blood the day before and got it on the first try. But medicine is an art. What worked the first time will not necessarily work the second time. I walked into the patient’s room with all the necessary equipment in hand: needle, tourniquet, alcohol swab, gauze, three tubes to collect the blood, and lots of confidence. My, oh my. Poor man. I must’ve stuck him 7 times or so that day. I was already sleep deprived, and with each try, I grew more tired, more frustrated, yet more determined to get it. And with each failure, I became less and less confident. I ran out of the room to grab more needles and tubes a few times; sweat started to run down my back, and it was becoming harder to stay focused, especially with the patient moaning and pulling back his arm as a reflex to pain. Amidst all that struggle, I stuck myself at some point. I stopped half a second to let out a sigh of relief because it was a clean needle that I had just taken out of the packaging, then continued with my day’s mission. After what must have been some 20 minutes, I finally obtained my three tubes of blood. I cleaned everything, thanked and apologized to the patient (who actually thanked me for being persistent and congratulated me!), and walked out of the room feeling like I had just left a battlefield. Suddenly all the emotions that I had tried to contain while working on drawing blood started flooding back and making me second-guess myself. Was that needle really clean? Did I stick myself after I had stuck the patient? What is the patient’s HIV status? Hepatitis C status? Am I going to have to alert the entire department? What is everybody going to think? Am I going to have to undergo HIV prophylaxis and take pills for months? How am I going have to pay for those meds? How am I going to live my life with HIV and Hepatitis C, both for which have no cure? Then I realized that I was being ridiculous and panicking for no reason, because I am certain that it was a new needle. So I packed my things and went home and took a nap. There is no room for fatigue and pride in medicine. What I should’ve done was to have someone else take over after I had already tried two or three times, instead of being obstinate on getting it myself. Just because I have successfully taken blood a few times does not make me an expert; and just because one is an expert does not mean that he or she should be overconfident. Well, consider lesson learned. (Thank you Dr. Fabrizio Montesdeoca for the lesson.) Left: Drawing blood from the radial artery. Right: Needlestick injury       July 7, 2010 I'm a Student, and Even I Know That Ever since I moved to New York City for my clerkship (part of the clinical training in medical school) at the Lincoln Health Center, I wake up every morning in a great mood. And that’s saying a lot because I have never been a morning person. After years of hitting the books, I am just so excited to finally try my hand at real medicine. So in spite of sleep deprivation, everyday I look forward to going to work, meeting patients, learning new cases, and performing minor procedures. Ok, to be fair, I shouldn’t call it “work” since I’m not actually getting paid for my training, but it just sounds better. Real hospital life is not Grey’s Anatomy (for those who don’t know, it’s a medical drama), however. Not everyday is exciting or even interesting. As a matter of fact, some days, such as today, can be painfully mundane and frustrating. The Lincoln Medical and Mental Health Center, located in the South Bronx, caters to a rather unique subpopulation of America. Most, if not all, of our patients are on Medicaid, or have no insurance. Many don’t speak English, which I actually quite enjoy because I get to practice my Spanish with my patients, but it can sometimes make history-taking challenging, in which case we call for a translator. Unfortunately, due to the fact that many cannot afford to see a primary care physician (the equivalent of our family doctors in Canada), they show up in our Emergency Room (ER) for everything and anything because by law, we cannot turn them away. As many of you undoubtedly already know, a major difference between practicing medicine in Canada and in the U.S. is liability. Doctors here have to constantly worry about covering their posteriors. The combination of people’s financial difficulties, lack of education, and doctor’s over-cautiousness from fear of lawsuits resulted in this patient that I saw today: A middle-aged woman who showed up in the ER because of a skin lesion on her foot. She was subsequently admitted by the ER physician to our department in Internal Medicine, meaning that she was hospitalized for further assessment and treatment. As I read her chart in the morning before going to see the patient, I perused different possible diagnoses in my mind: cellulitis (a type of skin inflammation and infection), angioedema (rapid swelling of the skin and underneath the skin), dermatitis (itchy inflammation of the skin)… When I saw the patient and examined her, I was flabbergasted and befuddled. What exactly are we looking at here? Where is the lesion that was severe enough to warrant hospitalization? Then my attending physician pointed the culprit out to me. Ladies and gentlemen, please hold onto your seat because you will not believe this. The “emergency case” was a callus! That’s the thick, hard skin that you get when you wear shoes that are too tight! I was absolutely stunned and stayed so for the rest of the day. This woman was there, taking up bed space, billing thousands of dollars to the government, when what she really needed was a pedicure! Why was this patient not sent home by the ER physician? Maybe he or she wanted (us) to make sure that it was not something more serious out of paranoia; you don’t want to get sued for negligence later on, or maybe the emergency doctor was just functioning on auto-pilot that day and admitting all the patients, sending them off to different departments. Who knows? But when I asked my team of physicians why this woman was here because she shouldn’t be, their answer was: You’re a student, and even you know that. Lincoln Medical and Mental Health Center, South Bronx, NY       April 14, 2010 Phew! I just received my USMLE Step 1 (please see previous blog entry for explanation) score and I am happy to report that I won’t have to see Step 1 ever again because I passed! Almost three months of gruesome studying during which I have, on several occasions, feared for my sanity, has finally borne its fruit. This is a big milestone in one’s medical career. Two years of medical schooling and it all boils down to these 7 hours of multiple choice questions. Want to guess what was the first place I went to after I had taken the exam? No, not a bar. I ran to the pharmacy.  Let me recount my USMLE journey starting from the night before the test. The night before I wasn’t feeling especially stressed, with only occasional bouts of nerves that lasted a few minutes at a time. I had planned to review until evening, eat a healthy dinner of fish that I had ordered from mom’s kitchen the day before so I can be smarter for my exam, watch some TV to relax, and go to bed early. I felt pretty calm, or so I thought. But when my mother told me that I couldn’t watch TV because she was following some stocks I just about flipped. I resorted to crying and pouting in my room. My plan was derailed and that is extremely destabilizing before an exam! Anyways, I ended up watching some shows on my laptop and then tried to sleep. Hours passed and I was wide awake. Despite not consciously feeling nervous, I just could not fall asleep, even after I self-medicated with sleeping pills. Eventually the Sandman did pay a visit and I got about four to five hours of Z’s before waking up at 6:30 A. M. Morning I arrived at the examination center 20 minutes before test time, handed in the required identification documents, only to have the receptionist tell me that I had printed out the wrong examination permit. Shoot! How can I be so stupid? I stayed calm… Could I please use the receptionist computer to print out the correct document? One of my classmates told me that she did not print out hers and had to run around town looking for a computer (she took her exam at a different center). I can just imagine the panic and sweat on her face! Luckily this receptionist let me use her computer. All documents processed, all personal belongs put aside in a locker (we’re not even allowed to wear a watch in the examination room), I sat down at my computer station and proceeded with the longest exam of my life. The exam consists of 7 one-hour blocks of questions and the test taker is allowed 45 minutes of break time to be allocated however desired. In other words, it was up to me when to take a break, how long I wanted to take a break for, as long as the total break time does not exceed 45 minutes. And can I just say that 45 minutes is very little! I took a short break after almost each hour just to refresh my mind. Plus the combination of nerves and caffeine did not bode well for my bladder. Each time I wanted to leave the examination room and come back, I had to sign in and out which took away maybe 10 seconds. It took roughly 30 seconds to walk to the bathroom, about 50 seconds to do my business, and 15 seconds to wash and dry my hands. And the clock kept ticking! The exam itself did not seem that bad, at least at first. It was similar to practice tests that I had taken before but after the first two or three blocks, the questions got harder. I had a lot of questions on biochemistry, molecular and cellular biology, my weakest subjects, and what I deem the most irrelevant subjects in medicine (Just for fun, ask your doctor if he or she remembers the pentose phosphate pathway). Previous test takers had told me that the main emphasis is on pathology, pharmacology and physiology, or as we med students affectionately call it, the Big 3 P’s. But every single person gets a unique set of questions taken from a bank of probably infinite number of questions. My 3 P’s were not as big as I had expected. Lunch Around noon, I decided to break for lunch. My test center was located in a business building and somehow I did not think that it would be appropriate to open my lunch box of fish (so all that omega fat helps my brain function better) and rice in the main lobby, where crowds of professionals in fancy suits cruised back and forth. With my head hung low and a grocery plastic bag in my hands, I finally found a quiet place to eat: the fire escape. I kind of felt sorry for myself, but decided to flip through my notes instead while I ate. Afternoon Twenty-five minutes later, I was back at my computer station. Stamina is essential in this kind of long examinations. Afternoons are usually when people start to lose focus. I was not going to let that happen to me, which was another reason I took frequent short breaks to avoid burn out. Oh, I forgot to mention earlier that I wore my lucky red underwear that day. I’m not a superstitious person, but whatever. Then, just as I was pondering very hard whether a certain type of receptor gets activated by phosphorylation, I felt something. Oh no. It is probably the worst thing that could happen to someone during a test, other than sudden attack of explosive diarrhea. Let’s just say that I was lucky my lucky underwear is red, and not white. To top it off, I had no feminine product on me, nor did any other women I asked in the bathroom, in the hallway, at the next-door office. I had to improvise. Well, at least the bathroom had toilet paper. The remaining of the test felt… uncomfortable. While hoping for maximal performance, I was also praying for minimal leakage. The necessary hourly bathroom visits added some disruption to my concentration, but I had to keep going. And then the moment came. I clicked in my answer for the very last question of my exam, and that was it: I had finished writing (or "taking," for my American friends) my USMLE Step 1 exam. I walked out of that building, looked up to the sky. Suddenly, the sun seemed to shine brighter, and the air seemed to feel lighter. I was not ecstatic, nor devastated, just dazed. It felt so surreal. And just then, I remembered that there was something else that was very real; that’s when I ran to the nearest pharmacy.       March 15, 2010 Studying for the USMLE I know that this has been a long hiatus and that I am much missed but I have a very good excuse: I have been studying for a monstrosity of an exam called the USMLE which stands for United States Medical Licensing Exam, or more colloquially known as “The Step 1” because this is the first of the three USMLE’s that I am taking. Most medical students take their Step 1 after their second year, right before they start their clinical training. It is an eight-hour exam testing all the knowledge that we are supposed to have learned and stored permanently from the first two years of medical school. I am scheduled to take mine in two weeks, if I don’t chicken out and postpone it. I will report back and let you know how it goes, if I come out of it alive. My "Bible" for the last couple of months.     November 15, 2009 So We Think We Can Hip Hop Bhangra! I have been in medical school for almost two years, and I still have not found the perfect balance between work and fun. This is my last term of basic sciences, before moving on to clinical clerkship, and it is just so hard to find the motivation to study as if I were cramming for my life every single day. I want to enjoy the island, spend time with friends, and leave with a fond memory of my two-year journey in Grenada. So that is what I did for the past month and a half. I slept at least 8 hours a night, managed to go out on school nights (gasp!) on a few occasions, went to the beach, got caught up on all my TV shows, and even performed a fusion of hip-hop and bhangra, a Punjabi folk dance, at St. George’s University’s bi-annual Indian Cultural Student Association (ICSA) show. I don’t know the exact numbers, but there is a large Indian community here at SGU. And every term, our largest lecture hall which holds 700 seats is filled with enthusiastic students and staff at the ICSA show. I had never gone to an ICSA show before, and I wish that I did. The amount of talent that is hidden behind studious faces I see in the study hall everyday is just astounding. I had no idea that my classmates could dance, sing, or act so spectacularly and professionally. Since it is our last term at SGU, a group of friends and I decided to do a little performance at the ICSA show. This way, if we end up making fools out of ourselves, at least we’re leaving and never coming back. For two months we met up weekly to practice and rehearse what turned out to be a 6-minute-dance of bhangra with a dash of hip hop. What’s interesting and funny is that only half of our group members are Indian, the rest are blond white girls, and well, me. Most of us had never done hip hop and/or bhangra before. I had never even heard of the word “bhangra”! It is a form of music and dance which originated from the Punjab region of Indian and Pakistan. Traditionally performed to celebrate the harvest festival, bhangra has now gained worldwide popularity. Even Jay-Z did a remake of the bhangra song “Mundian To Bach Ke” or “Beware of the Boys”. The day of the show, which happened to be the day right after our last midterm, was filled with anxiety and panic. We hadn’t been practicing a lot because of exams and did not feel ready to perform in front of 700 people! But 7 o’clock came, and we put on our Indian outfits and went on stage. The show was a hit! Everyone loved our performance, and even though we made a few mistakes here and there which our friends were kind enough to tell us that they were not noticeable, we thoroughly enjoyed ourselves. And isn’t this what it is all about? The performance adrenaline rush was followed by a night of dancing and partying at our semi-formal, the Unity Ball. The one time that we all get out of our sweat pants and study outfits and get dressed up. Girls with pretty dresses and boys looking dashing in their suits. But it turns out that “enjoying ourselves” is not what it is all about. Not all the time anyway. Our midterm grades were posted the next day, and well, let’s just say that my mentality of “I want to enjoy my last term on the island” showed in my grades. Yikes. I passed, but it was not a pretty sight. So I guess now it is time to give up the fun and buckle down for the finals. Some say that you can manage both, work and play. But I have yet to find out how. P. S.: For those interested in seeing our performance, here is a youtube link. Our Bhangra dance team.     September 5, 2009 Daydreaming About Drugs The weather is so beautiful out - at least it looks so from my window - I should’ve gone to the beach or something. Instead, I decided to stay home all Saturday and study. But I should know from experience by now that when I stay home, I usually don’t get much done. Instead, I spend way too much time surfing the web, making snacks, cleaning and tidying my room, philosophizing about life… basically anything that will distract myself from any serious studying, including daydreaming and talking to myself. Yes, that’s right; I have a very rich inner world. In that respect, I can sort of relate to John Dorian from Scrubs, or Ally McBeal. Although I do not spontaneously break into songs or see naked babies walking on the street, I am quite adept at entertaining myself. The thing is, I really hate memorization. And so far, that is what pharmacology is: pure and dry memorization of words that I can’t even pronounce. I guess it goes with my imaginative personality that I respond better to stories. In pathology last term, for example, we learned how a pathogen causes a disease, how the latter manifests itself, and what can be done to make it all better. There was a flow and logic to what we were learning, and it was interesting. I am sure that learning about drugs is very interesting, too, but when you have to cram some 400 drugs and their mechanism of action, adverse effects and uses, all that in barely two-week’s time, something fun becomes a chore and a source of helpless panic.  However, pharmacology has, I must admit, brought a smile to my face on occasions. For example last night, as I was reviewing autocoid* drugs, I found out that cimetidine (trade name Tagamet), a second generation H2 blocker (histamine receptor 2 blocker) used to decrease gastric secretions, also binds to androgen receptors in high doses, thereby blocking the effect of the male hormone androgen, causing gynecosmatia (breast enlargement in men) among other things. I seem to remember having taken cimetidine before for my heartburns; I wonder if the same side effects apply to women? And Alprostadil, or prostaglandin E1, is a vasodilator (it dilates vessels) used to treat impotence; but you have to either inject it into the penis or insert it into the urethra. Now that gives a whole new meaning to “foreplay”, doesn’t it? I told you I was good at entertaining myself. *Autacoids are biological factors which act like local hormones, have a brief duration, act near the site of synthesis, and are not blood borne. Autacoids are primarily characterized by the effect they have upon smooth muscle. (Wikipedia)   The injectable form of Alprostadil (Brand name Caverject) August 15, 2009 Back to School... For the Last Time! This is my last semester in Grenada! Once all exams passed, I will be starting the clinical part of my training called "the clerkship" in a New York hospital. I probably will miss some aspects of Grenada, such as the all-year round tropical weather; but I am very eager to get out of the classroom and get my hands dirty.  Actually, this term we will get to have a little taste of the hospital life. Once a week, we are taken to a local hospital for rounds, where we get to observe, and sometimes get involved, in different branches of medicine. I think it will be very interesting to see how a Caribbean hospital operates. Many Montrealers satirically compare our hospitals to the third-world country. And although I know that the Quebec health care system has much to improve on, I will let you know if it really is as bad as a developing country.  As for my last semester of "classroom-dom," Pharmacology, Pathophysiology, and Clinical Skills are on the menu. Pathophysiology should be some sort of review between Pathology and Physiology, which we have already studied in previous terms. Pharmacology, the study of drugs, is a whole new subject. I am currently staring at my packet of notes from the first week of class, already thick enough to massacre any tropical insect that might sneak their way into my room.  It is so hard to get back to study mode! But you've got to do what you've got to do...   July 29, 2009 Sun at the End of the Tunnel I had been living the same robotic routine for so long that I started to believe that there was no light at the end of the tunnel. But there was, the semester did finally end! I remember bubbling in the last answer on the scantron for the very last exam of the term. Usually, if I have time, I will go over the questions a second time, which is what I started to do. But after three questions I couldn’t take it anymore. All I wanted to do was to get out of there. And that’s exactly what I did. I walked out of the over air-conditioned lecture hall, took off my layers of sweaters, and felt the Caribbean sun on my skin as if for the first time. It felt almost surreal. I couldn’t believe it was over! Ecstatic hoorays exploded from left and right, and beer bottle caps were popping high. See, we fourth semester students were the only ones left at St. Georges – everyone else had already gone home for their summer break. This was the longest semester in medical school, so it was especially exciting to be done. I had one thing on my mind, and that was not to go back to Canada paler than I had left! I know, I am a medical student, and I should know better than to subject my skin to the deleterious effects of ultraviolet (UV) light.  But my only exposure to light all semester consisted of desk lamps and now vanity convinced me to get at least a bit of tan! So to the beach I went, and grilled. Not for long, however. The noontime sun was very aggressive, and although I do like the look of a tan, sunbathing is actually not one of my favorite activities. I much prefer a gentler climate. Plus, the little nagging voice whispering photoaging and skin malignancies inside my head was making me feel guilty. UV light is subdivided into three groups based on wavelength: UVA, UVB and UVC, in descending order. UVC, composed of the shortest waves, it is the most destructive one. Most of it is filtered out by the ozone layer of Earth’s atmosphere, but that protection has been compromised due to modern pollution. Our most immediate concerns, however, are UVA and UVB. UVB’s direct relationship with skin cancer has been established for a long time, but it wasn’t until a couple of years ago that scientists started to realize that UVA can also cause skin cancer. This is because UVB’s damage is much more visible than UVA’s – it is what causes skin reddening and tanning – the latter being our natural protective mechanism against harmful ultraviolet light. These visible skin changes allowed the introduction of the concept of SPF, or Sun Protection Factor, back in 1962. Today, it is the worldwide standard for measuring the effectiveness of a sunscreen when it is applied at an even rate of 2 mg per cm2 of skin surface. That’s about a shot glass of sunscreen for the entire body. In the laboratory, scientists measure the time it takes for a subject to burn with the sunscreen being tested, and then divide that number by the time that it takes for the same subject to burn without protection. The obtained number is the SPF. But in reality, most people do not put on a shot glass full of sunscreen, and they do not reapply frequently enough, which should be every 2 to 3 hours. Therefore, the actual protective power of a sunscreen as commonly used is much less than that under testing conditions. Moreover, many do not realize that the SPF only refers to protection against UVB, not UVA. Fortunately, more research allows for more scientific advancement, and new products are being formulated which offer protection against both UVB and UVA. Look for sunscreens with Mexoryl, titanium dioxide, or zinc oxide for a more complete protection from skin cancers, premature skin sagging and wrinkles. As for myself, I shall try to practice what I preach during my short summer vacation, although I think I can indulge in a bit of mild Montreal sun before I head into another tunnel… Med students getting some sun after exams. May 7, 2009 "Buried Alive" They say that this is supposed to be the hardest term of medical school. “They”, being other students who have gone through the same ordeal, and this term being the first semester of the second year in medical school at St. George’s University. Actually, it’s not that hard. It’s just the perpetual marathon that has some of us want to stop and collapse midway. But you know how it works in a marathon; you stop and you risk being trampled to death by other runners. I actually enjoyed the beginning of this term. Sure, it was busy, but I like busy, plus the material is interesting, and we were just starting to finally emerge out of basic sciences and having a taste of what real medicine is like. From 8 A.M to 12 P. M., we have lectures in Clinical Skills, Microbiology, and Pathology. In the afternoon, we have two hours of pathology lab where we each have to take turns presenting slides illustrating diseases that were assigned to us, followed by two hours of lab in clinical skills, which pretty much means “playing doctor” with our fancy US $800 medical kit that we all had to purchase before coming to SGU (I’m way too cheap and poor for that, I just scramble around and borrow from people). It was all very fun and exciting, and although Pathology was a lot of work, it was my favorite subject so far in medical school. After all, it is the study of the causes, nature, and effects of diseases - It is medicine. But now, to quote my good friend Natasha, it just feels like we are being “buried alive”. First of all, this semester is six months long, instead of the usual four months. Aside from being far from our families and friends, such a long semester is just physically and mentally exhausting. Some people are stressed (a more accurate term would be "freaked out"), and you can tell who those are by their bloodshot eyes from sleepless nights and their hand tremors from caffeine overdose; others, like me, are just jaded. I almost don’t want to care anymore. All the diseases just blend in together; I don’t even know which is which. Do you want to hear something funny? Our second set of midterms end on Monday May 18th at 9 A. M., and classes resume that same day at 10 A. M. One hour of break is all we get. Hilarious. And instead of cramming, I am here complaining to you all, because that’s what medical students do: We complain. Cheers.   Second year medical students at SGU during pathology lab.   March 11, 2009 What does it mean to be mentally ill in Grenada? “It means that the person is going to kill!” is what an average Grenadian would say, at least that's what the Housing Director of the only Mental Hospital in Grenada told us when a group of medical students from St. George's Univeristy and myself went there for a visit one afternoon. There is no simple answer to define the term “mental illness” or “mental disorder”, a more commonly used term in international clinical documents; but it certainly does not mean that a person who is afflicted by such a condition is “mad” or “going to kill”. In North America, thanks to education and active efforts to raise awareness by various groups individuals and organizations, people have a better understanding and are slightly less judgmental about mental illnesses. Unfortunately, there is still much stigma attached to mental disorders, and even more so in Grenada, so much that a person who is suffering in his or her mind is thought to be totally crazy and equal to a rampant murderer. No, having a mental disorder does not mean that you are crazy. In general, it means that you have a clinically significant behavioral or psychological pattern that is causing you distress, disability, or increased risk to suffering. The term “serious mental illness” is sometimes used to refer to more severe and long-lasting disorders. Mental disorders cover a very broad definition. It could mean depression, characterized by, but not only, chronic feelings of sadness, change in appetite and sleeping patterns, loss of interest, lack of energy, and in more severe cases, suicidal ideation or even attempts. Specific Phobia is another mental disorder; some common ones being claustrophobia (fear of enclosed spaces), agoraphobia (fear of public places), and acrophobia (fear of heights). Being simply afraid of something does not qualify someone as “phobic”. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the criteria for specific phobia are: Excessive, unreasonable, persistent fear triggered by objects or situations; Exposure to the trigger leads to intense anxiety; The person recognizes the fear is unrealistic; The object or situation is avoided or endured with intense anxiety. What is interesting about this disorder is that the person realizes that his fear is irrational, but he still cannot control his emotions or behaviors. Likewise, people with Obsessive-Compulsive Disorders (OCD) understand that their behavior is irrational but they cannot help it. For example, a person with OCD might feel the need to switch the light on and off a specific number of times a day. She knows that it does not make sense, but if she does not go through with her ritualistic impulses, she will be overcome by unbearable anxiety. Unlike phobias or OCD, those afflicted with schizophrenia do not always realize that they are sick.  Schizophrenia is a mental disorder characterized by abnormalities in the perception or expression of reality; most commonly manifested by auditory hallucinations, paranoid or bizarre delusions such as believing that they are being persecuted by the government or extraterrestrial aliens, and disorganized speech and thinking. The disease usually strikes in early adulthood, and affects up to 1% of the total population. And because the voices they hear can be so disrupting and the delusions so convincing, these people struggle to distinguish reality from imagination, hence often have a hard time functioning normally and many end up homeless. The majority of the patients at the Grenadian Mental Hospital suffer from schizophrenia or other kinds of psychotic disorders. Many of them were forcefully brought there by the police, or what the locals call the “babyland” (not sure of the spelling). Because of social stigma and of the burdens that they can be, family members of these patients often are not willing to take them back. So a lot of them have to call the hospital their home, until they die. And let me tell you, that hospital did not look like the Ritz-Carlton. Refugee camp is more like it. Men and women were separated, locked behind heavy metal doors. I was ignorant enough to ask if patients had their own individual bedrooms. The Housing Director looked at me and chuckled. Of course not. I cannot even begin to describe the immense wave of sadness that washed over me when I saw their living conditions. One room for men, one for women. Concrete floor, metal bed frames that didn’t look too sturdy, old bed sheets, harsh neon lights, and hot, stale air. The whole place looked gloomily miserable and yet was better than most places they came from. I cannot imagine how someone with Major Clinical Depression could feel better in such an environment. And of course, that person would not be receiving the latest generation of antidepressants either because the government cannot afford them. After our tour of the country’s only mental hospital which has an 80-bed capacity but over 120 inpatients, the medical students were given the chance to interview two patients who were deemed to be stable and harmless enough. Both were in their mid-twenties, both suffered from some form of schizophrenia, but they also had some major differences. Dwayne* was very jovial and talkative. In fact he was so talkative that it was difficult to end our interview with him. He denied hearing voices that other people don’t hear, and instead, talks about his big fortune and how his mother has been trying to kill him to steal that money from him. Of course, that story could be true, but when we started asking specifics about his story, the facts did not connect. Dwayne knew that he was sick, but didn’t exactly know sick from what. Giselle*, a strong young woman in her mid-twenties, looked almost hostile. She spoke rather loudly, almost on the aggressive side (we look at speech patterns in diagnosing a schizophrenic). She volunteered the information that she has two daughters who she misses very much. That was about the only time she smiled. The difference between Dwayne and Giselle is that Giselle admits to hearing voices but does not know where or who they are from, or why she’s hearing them. She seems to realize that she is sick and needs to be treated. One difficult thing for Giselle is that she gets conflicting messages from two distinct voices. One voice saying very negative things, and the other voice telling her to pray to God. Not unlike the devil and the angel on each shoulder! Giselle believed that she was leaving the hospital that upcoming weekend to see her daughters, and we all believed her, too. But we were later told by the Director that no visit has been scheduled for her, and that her own mother who is taking car of the two children does not want the responsibility of taking care of her sick daughter, too. I left the hospital with many mixed emotions. Of all mental illnesses, schizophrenia is truly a terrible one. Although it can be managed by medication (but not always), no cure has been found, and the medications often come with very undesirable side effects, such as Parkinson-like tremors. It was somewhat comforting learning that Grenada has a public healthcare system; therefore as impoverished as many are, citizens do not have to pay for health services or medication. But even the government has limited resources. The hospital was in dire need of basic renovation, and how sad is it that patients have to settle for older-generation and less efficient drugs? We might not be able to make the Grenadian Mental Hospital brand new. We might not be able to offer every single sick person in the world the best medication available. What we can start to do, however, is to change the way we view mental disorders. People with mental illnesses are sick and need help. Just as a diabetic needs to be monitored by her physician and follow treatment, a psychiatric or mental patient needs professional intervention. What does it mean to be mentally ill? It means that you are suffering, that you are in pain. With the appropriate care, the suffering can end, the pain managed. This can be said about any other diseases, can’t it? *Pseudonyms have been used to protect patients' privacy View of the Mental Hospital from the back. This is the Women's Ward. Front entrance to the Mental Hospital January 15, 2009 Finding Nemo in Grenada I saw redband parrotfish, bluehead wrasse, spotfin butterfly fish, eel, even a great barracuda, but no Nemo! Nemo is a clownfish, and I guess they don’t live in the Caribbean sea… As a matter of fact, after some research, I found out that clownfish build their homes in the Indian and Pacific oceans, including the Great Barrier Reef and the Red Sea. Even though I did not find Nemo, I absolutely loved my scuba diving experience. It was scary at first, I must admit. After only one morning of theory and practicing basic skills in the pool, our instructor took us out to the ocean and we were to go 18 meters deep for a whole hour! The key is to stay calm and breathe slowly. Once you’re calm, it is absolutely fantastic down there. It is such a different world – so peaceful and yet mysterious. Reefs and corals of all shapes and colors, different marine creatures swimming by your side, above or below. Unfortunately, I was not able to complete my scuba diving course by the end of last term due to a cold. Diving with a sinus congestion either due to colds or allergies can make equalization difficult or impossible. During descent, water pressure increases and compresses the air in your body air spaces (the sinuses). As you continue to descend, this becomes uncomfortable and maybe even painful. This is called a squeeze, and happens most frequently in the air spaces in the ears. To avoid this, you must equalize the pressure between your sinus and the water. This is simply done by pinching your nose shut and gently blowing against it with your mouth closed which directs air from your throat into your ears and sinus air spaces. Another technique is swallowing and wiggling the jaw from side to side. Now that I’m back on the island after a short winter break, I can get return to the underwater world… no Nemo, but I would love to see a giant sea turtle!     October 1, 2008 A Crab in My Class Where else but in the Caribbean would a crab casually waltz in in the middle of a physiology lecture! We were all intently listening to our professor explaining something in cardiophysiology when all of the sudden a group of students clamored up. Even the teacher got curious and asked what was going on. A crab is with us in the lecture hall! It seemed like Mr. Crab that day felt particularly intellectual and wanted to sit in in our physiology lecture. That or he just got confused as to where the beach was. I thought it was pretty funny, but not everyone shared my opinion. We had just finished studying parasitology and a lot of students were feeling quite paranoid about catching something (if you saw the disturbing pictures of things crawling out of a person’s body from all possible orifices, you would probably be pretty grossed out, too). I don’t think I suffer from the typical MMS, or “Medical Student Syndrome”, where med students think they have every disease that they are currently studying. The week after our parasitology exam the anti-parasite shelf at the pharmacy was completely cleared out! No doubt by my classmates who probably ran there directly after the exam. My roommate took some even though she has no symptoms of parasite infections, but “just in case”. To her relief, nothing wormy came out in the toilet. Anyways, back to the crab. The reason some students got grossed out is because we had just learned that crabs may be a carrier for the parasite Paragonimus westermani, aka the lung fluke. Parasites need to live in a host in order to survive and replicate. In the case of Paragonimus westermani, fresh water crabs are one of the hosts. By eating raw infected crab or crab paste, the parasite can be transmitted to humans and lodge in the human lungs or heart. This can result in bronchitis, bloody sputum, and even death. If you were reading carefully, however, you would know that my classmates’ fear of contracting the parasite from the crab is unfounded. The parasite lives in freshwater, and we are surrounded by the ocean, which means that that lost crab couldn’t have been infected with Paragonimus westermani! This goes to show that it’s important to do your research before panicking!       August 30, 2008 Back to School... but Carnival First! I got back to Grenada on August 8th, a couple of days before school started so I could settle in properly, but mainly to enjoy the last days of Carnival! Carnival has its origins from the early followers of the Catholic religion who started the tradition by holding a costume festival just before Lent. Since many foods, including meat, are forbidden during Lent to commemorate the Passion of Jesus, people held a wild celebration right before, calling in Carnival, which comes from the Latin word carne, meaning meat. Today, the Carnival is celebrated everywhere around the world, but is mainly associated with the Caribbean and South America, with Trinidad and Tobago as probably the country with the most elaborate celebrations. So Sunday night, after a day at the beach and a nap at night until 3:00 A.M., my friend Snow and I put on our ugliest and oldest clothes to head to one of the last events of the Carnival: J’ouvert (pronounced “juuvay”). First, we went to a local bar to join the rest of our friends who didn’t need a nap. Flatbed trucks blasting Soca music were waiting outside the bar to take us downtown. A couple of drinks later, we grabbed cups of paint and oil, hopped onto the truck. Now, we are ready for J’ouvert. J’ouvert is a contraction of the French jour overt, or day open (morning). It starts around 4:30 A.M. and people dance all morning on the streets to the beats of drums and Soca while rubbing paint and oil at each other. Now you know why we didn’t wear our favorite outfits to the party! Red, yellow, white, green, and black were the main colors. Each flatbed trunk led by a DJ had a different color. Our team color was red and people were absolutely merciless! Within minutes my entire body, face and hair were covered in paint! At first, I thought all this paint throwing and street dancing seemed a bit random. But then a local explained to me that it is sort of their version of Halloween… the paint serves as a camouflage from evil spirits, or maybe historically as a way to hide from enemies. Interesting… More interesting is that instead of candies, we get rum!   J'ouvert in Downtown St. George's, Grenada   June 23 , 2008 Doctor in Making Wow. Time really does fly. First term of Med School is over and I’ve been back home for a month now. And after four intensive months of anatomy, embryology, histology, biochemistry and bioethics, I am now one eighth of a doctor. Thinking back (not that it is over), I am really glad that I went to Grenada. Sure, it wasn’t an easy decision to make at first; drop my life in Montreal and move to an island that I had never even heard of before, go to Medical School in a third world country where I can’t just go out the door and grab a cup of coffee or some midnight snack, leaving my family and friends and putting myself in debt so deep that the thought of it made me nauseous at times… all those things were so incredibly intimidating to me. But what a unique experience this journey has been and will go on to be! Although four months doesn’t sound very long, the curriculum is so rich that we managed to learn an impressive amount of information. I can now tell you how a single cell becomes an embryo and how the latter develops into a fetus which, eventually, in most cases, grows into a healthy baby. It really is magical, and there is still a lot that we don’t understand, but medicine is forever changing, and thanks to all the progresses, we are able to offer preventative measures or treatments, even cures, to our patients. For example, it has become standard to advise women who are planning to get pregnant and women in their early pregnancies to take folic acid supplements to avoid neural tube defects in their unborn babies. Neural tube defects are birth defects that occur when the neural tube does not close properly during the early weeks of pregnancy, resulting in abnormalities of the spine, brain or skull. If the baby survives, a lifelong disability is often unavoidable. The most common neural tube defect is spina bifida in which a portion of the spinal cord is found outside the vertebrae. Taking 0.4 mg of folic acid a day is an easy way to significantly reduce the risks of neural tube defect. Dark green vegetables and whole grain bread are also very good sources of folic acid. We also learned to look at microscopic slides and recognize different types of cells, a skill that will come in handy later on in pathology. Our short term memory was invoked in biochemistry where countless pathways had to be learned with no detail spared. The challenge was to hammer our newly learned knowledge from the short to the long term memory while new information kept pouring in! But the first term is done, and I survived. Before I left the island for summer vacation, I made sure I went to the street market in downtown St. George’s to buy some souvenirs for people back home. When I say downtown, do not imagine Eaton Center, skyscrapers, and cars coming from all directions. Rather, picture a cute village surrounded by mountains and water with narrow roads, small shops, and street vendors behind a stand or in a wooden shack. Granted, shopping isn’t quite the same, but it does have its charm. I came home with various spices, natural loofahs purchased on the beach that my girlfriends much appreciated, and of course, lots of rum! Now, finally some relaxation, and well deserved might I add! Street Market in Downtown St. George's, Grenada   March 31, 2008 Post Midterms - Med Students Gone Wild Ahhh midterms! A time for trauma! I was on no sleep, chips and candy diet, because I was so afraid that if I even dared to sleep or take time to eat, I would fail out of med school. Cleaning my dorm room was an even more ludicrous concept. So for an entire week, I was an emotionally unstable zombie rotting in my own filth. Crying spells and manic hysteria were involved. Plus I think I had a caffeine overdose. As some of you may know, foods such as coffee, spices, onions and fatty meals can relax the lower esophageal sphincter in susceptible individuals, the junction between the stomach and the esophagus, resulting in stomach acid ascending into the esophagus. Since the esophagus does not possess the same protective lining as the wall of the stomach, the presence of acid in the esophagus can be very painful. That’s what heartburn is. Most people get mild heartburns from time to time, but long term chronic acid reflux can cause physiological changes in the esophageal lining and develop into esophageal cancer. I am one of those susceptible individuals who suffer from heartburn quite frequently. Therefore my daily dilemma was: drink more coffee and red bull to pass my exams and run the risk of getting esophageal cancer later, or flunk out of med school and not get cancer later. I passed everything. After midterms, med students are like teased bulls finally released from their cages. We go crazy. The school probably won’t be happy about my saying this, but it is a fact: Med students drink until they think they are going to throw up and pass out, and then drink some more! And yes, these are the people who will look after your health in the future. I am getting a little too old to be so wild (I just turned the big two-five). Between the all-day all-you-can-drink beach party and the early catamaran cruise trip the next morning, I actually went home and slept a bit. My dear friend, who I will call Keyser, partied all day, all night, slept an hour or so, and made it to the 9 A. M. cruise! After I carried his inebriated self to bed after our little sea trip, Keyser finally caught some shut-eye. But don’t you think that it was over! Keyser woke up and partied until the next sunrise. Do you know how I know that Keyser will make a great doctor? He will have no problem with the long shifts… And it is with great pride that I say that he’s another fellow Canadian. We Canadians definitely out-drink Americans! Yes, that entire weekend was wild, and I loved it. That’s what med school is about, work hard, party harder! Of course, other than getting myself intoxicated responsibly and with moderation, I made sure that I did some sight-seeing as well. We did some snorkeling on the cruise and saw the world’s first underwater sculpture park, built in May 2006 by Jason de Caires Taylor. Statues of men and women under water, holding hands or sitting at a desk, surrounded by multicolored sea creatures, it was magical. Alas, now I have to drag and pull myself back to reality. My brain completely shut off during the last two weeks and refused to retain any school-related information. But I did it once and shall do it again… As for Keyser’s wild ways? I’m sure he will buckle down before finals and do even better than my tame self. Underwater statue March 3, 2008 I Am Alive Airway: clear. Pulse: 65/min. Blood pressure: 110/65. Yes, I am still alive. I know it’s been a while since my last entry. Maybe you thought I was buried alive under mountains of books and atlases. Well, not yet, but almost. I had a bunch of tests last week. Even though they didn’t count for much – we were told that the tests were designed to give us an idea of whether we are on the right track – the pressure that we put on ourselves was still enough to drive some of us to tears. Yes, I admit, I cried. Dr. Loukas, one of my anatomy professors, mentioned in the beginning of the term that medical school is a lot of crying. And apparently guys cry just as much as us girls, if not more. The trick is to cry in the shower, then come out and act completely nonchalant. “My red eyes? Oh, it’s just shampoo.” So let’s just say I’ve been getting a fair share of shampoo into my eyes. My results turned out okay in the end. Histology was actually my highest mark. That doesn’t mean that I’m any better at identifying slides of microscopic structures though. But, as promised, I will reveal the real name of that modern art-looking pink and purple blob from my last entry. It is actually a highly magnified image of the epithelium, or top layer, of the tongue. The top dark pink section with purple spots is what we call stratified squamous cells. Stratified means multi-layer, and squamous cells just means flattened cells. Each purple spot is a nucleus in the middle of each individual squamous cell. These cells form a thick, protective layer, and makes up the outer portion of the skin. The tongue and the esophagus, like the skin, are subject to a great deal of abrasion, and so the outer surface of the tongue and the inner surface of the esophagus consist of stratified squamous epithelium. The lining of the vagina also consists largely of stratified squamous epithelium. The cornea of the eye is another place where you can find stratified squamous epithelium. But alas, it’s an imperfect world; just because a tissue is classified as “stratified squamous epithelium” doesn’t mean that every cell in it is flat. Typically in stratified squamous epithelium, the uppermost cells are squamous in shape, while the deeper ones are more cuboidal (cubic shaped). That’s pretty much all I know for now. So far I’ve told you about anatomy and histology. I haven’t mentioned biochemistry yet because I absolutely abhor it, and most people I know do. I would define biochemistry as the study of chemical pathways in the body. It is highly intricate and detailed, and in my opinion, (almost) entirely useless in the medical profession. But I can’t become a doctor if I fail my midterm, which is coming up soon, so I’d better go and squeeze as much info into my brain as I can, and hope it stays there! "Pink & Purple Blob" a.k.a Stratified Squamous Epithelium of the Tongue   February 7, 2008 She Looks Too Plain, Have Cosmetic Total Treatment It is only the third week of med school and I already feel like I’ve been here forever. The amount of information that bombards us every waking moment gives us the illusion that we have been here much longer than in reality. For example, the entire axilla (underarm), arm and hand were taught in merely five hours. And that includes the accompanying nervous, muscular, vascular and lymphatic system. Students are expected to know the newly taught material like the dorsal side of their hands (i.e. the back of their hands) which is mainly innervated by the radial nerve and its branches by the beginning of the following week. Falling behind is absolutely not permitted and yet inevitable. I must admit that I had a mini-meltdown this past weekend. I know what you’re thinking: But I just started! Well, I am feeling better now. And I do love anatomy. I mentioned that the dorsal side of the hand is innervated by the radial nerve which is responsible for the extension of the wrist and fingers. When the wrist is extended, the angle between the dorsal side of the hand and the forearm decreases. During flexion of the wrist, however, the angle between the palm and the inner forearm decreases. So when the radial nerve is severed, say from an accident, the affected person would lose his ability to extend his wrist, so he would have what we affectionately call a “drop hand”. Med students often use mnemonics to help them remember things like that. DR. CUMA for example stands for: Drop hand if the Radial nerve is injured; Claw hand if the Ulnar nerve is injured; and Ape hand if the Median nerve is injured. A friend of mine came up with his own mnemonic this week: She Looks Too Plain, Have Cosmetic Total Treatment. The first letter of each word stands for a bone in the carpus (the base of the hand close to the wrist). For those who are interested, those bones are actually the scaphoid, the lunate, the triquetrium, the pisiform, the hamate, the capitate, the trapezium, and the trapezoid. I didn’t even have to look in my atlas. See? Mnemonics are wonderful. As much as I love anatomy, it is tremendously time-consuming. I barely have time to study the other subjects so I am really behind in histology, biochemistry and embryology. Oh, and bioethics, too, but no one cares about that. Just don’t tell the teacher. We don’t have school tomorrow (February 7th) because it is the Grenadian Independence Day, otherwise known by the students here as Catch-Up Day. I plan to study histology, which is basically microscopic anatomy or the study of cells and tissues under a microscope. Maybe by next week the microscopic slides won’t all look like pink and purple blobs to me. "Pink & Purple Blob" Real scientific name coming up next week January 24, 2008 First Week of Med School on Paradise Island I’ve been here exactly one week now. The first couple of days were magnificent, aside from the fact that my luggage did not arrive with me, which I hear is rather common. Thankfully it made its way to the airport safe and sound two days later. The campus looks almost like a vacation resort and everyday we had different orientation activities: going to the beach (Grand Anse beach is 10 minutes away from my dorm and is absolutely splendid), swimming in waterfalls, going to local street markets and bars… I felt like I was in summer camp and I loved it. My favorite part would have to be the Annandale Falls. I had always dreamed of swimming under a waterfall and it was even better than I had imagined. The water was perfect, the falls hitting on my back acted like a natural massage jet… just heavenly! Right now, however, I am not in heaven. Classes started two days ago and let me tell you, it is INTENSE. Well, I guess if it weren’t so I would be worried. But that doesn’t mean I’m not scared or intimidated. St. George’s University follows the American system, which I am not quite used to. Instead of a block system – meaning that students study one subject after another – we have a traditional system like in undergrad or high school. So right now instead of focusing on one subject, we are studying five subjects simultaneously: anatomy, biochemistry, histology, embryology, and bioethics. I have to say that the most interesting subject is anatomy, but it is also the most daunting. First day we were assigned 100 pages to read and memorize. In merely two hours the professor covered the entire spinal system, back and thoracic muscles, innervation and blood supply. How am I supposed to digest all this information in such a short amount of time you ask? Dear readers, I have no idea! I guess I’ll just have to find my rhythm and routine… soon! Anatomy is not just about dry memorization, though. Mastering anatomy is crucial to understanding how the body works and practicing medicine. For example, if I didn’t know that the spinal cord (a bundle of nerves in the vertebral column extending from the head to the lower back) ended at the first lumbar disc (L1), I wouldn’t know that I have to go below that point to perform a spinal tap or lumbar puncture in order to avoid injuring the nerves. A lumbar puncture is performed by using a rather large and scary needle to obtain a sample of cerebral spinal fluid (CSF) in the spine for diagnostic purposes. The needle has to be inserted between L3 and L4 (3rd and 4th vertebral disc) or L4 and L5. At that level in the adult, there is little danger of damaging the spinal cord. Alright I’d better go study some more… and how are you folks doing back home? Enjoying the snow? Annandale Falls January 15, 2008 The Beginning of a New Journey “Mama always said life was like a box of chocolates. You never know what you’re gonna get.” This must be one of the most famous lines in contemporary American cinema. We’re talking of course of Forrest Gump. Life is indeed full of the unexpected. Just a year ago, I never would have imagined that I would one day move to the Caribbean to study medicine. And yet that is exactly where life is taking me. In fact, I leave Montreal in two days. Destination: St. George’s University School of Medicine in Grenada, West Indies. St. George’s University (SGU) received its first class of medical students in January 1977. Undergraduate, graduate and veterinary programs were subsequently added. The medical program is, like most medical schools in North America, four years. The first two years are to be completed on the island and are comprised of basic science training in the form of didactic lectures, laboratory experiences and problem-solving small groups. The last two years consist of clinical rotations in affiliated hospitals in the U.S. or U.K. When all that is completed, I will be an M.D.! I have been bringing you, dear readers, scientific tidbits for the past four or so years, which I hope you have found interesting and informative. Now, as I embark on a new journey to pursue medicine, I’d like to invite you (to the Caribbean!) with me. Through the McGill Office for Science and Society, I will keep you updated on my life in Grenada, interesting things I learn in medical school, and also occasionally post pictures of sunny beaches! Hopefully my adventure in Grenada will be like a box of chocolates: sweet and healthy! St. George's Univeristy