Saturday, October 26, 2013

Rite of Passage

We’ve survived.

The first anatomy exam is over.

*insert sigh of relief here*

As I wrote about previously, Loyola just changed up their anatomy curriculum. Most of the changes, at least in my opinion, are for the better. The one change that we were all nervous about, though, was the switch from in-lab anatomy practical exams (where you wander around in the anatomy lab and try to identify labeled structures on cadavers) to online practical exams (where the instructor takes a picture of the labeled structure, and you have to figure out what in the world you are looking at). 
From Anatomy at the Bleeding Edge

Intuitively, it seems like an in-lab practical would be the better course. With anatomy, it’s often helpful to be able to orient yourself to the region of the body you are in and look at a labeled structure from several different angles while you are figuring out what it is. With a picture, on the other hand, we were afraid that we wouldn’t really be able to orient ourselves or see the structure clearly. Looking at pictures of a cadaver can be an entirely different experience than seeing one in the flesh (I know, that was too easy…). In fact, having done a couple of online practical exams as practice before the test, I know all too well that badly-taken pictures can be downright frustrating.

Despite all of that, the general consensus among the students – and I agree – was that the instructors did a great job in creating the online practical. All of the pictures were of good quality, structures were pretty clearly labeled, and they did a good job of orienting us to the region by showing us where exactly in the body we were and making an effort to clearly show neighboring structures.

There was also the benefit of being able to take your time while trying to identify a structure. I took anatomy in undergrad (and subsequently forgot everything…but ah well), and we had in-lab practical exams. These generally consisted of a large mass of students wandering somewhat aimlessly around a locked-down laboratory with a sheet of paper, a clipboard, and a pen. While it is helpful to be able to look at a given structure from multiple angles, at the same time you did feel somewhat rushed by the bolus of students coming down the line behind you. With the online practical exams, however, you could stare at that darn picture however long you pleased, thank you very much. So that was nice.

I was pretty happy with the results of the exam. The class as a whole did pretty well, actually. Anki really shines in anatomy, particularly the image occlusion feature, which allows you to screen-capture a picture from your computer, cover labels, and quiz yourself using Anki’s spaced-repetition algorithm. Since anatomy is all about visual recognition/spatial thinking, Anki is perfect for this subject. It’s much better than staring at a picture in a textbook until you think you have it, only to forget it a week later.

As far as studying for the test – and anatomy in general – goes, I really didn’t spend much time in lab. I generally attended lecture, which I found to be helpful, and then came home and made Anki cards for what we learned that day from lecture slides, Thieme’s Atlas of Anatomy (which has some beautiful pictures), our online dissector (which has a lot of the Thieme pictures), or one of the Lippincott Concise Illustrated Anatomy books (which comes with an access code for on online version of the book on a great e-book platform – awesome for making cards). Also, before or shortly after starting a new region of the body, I tried to watch the relevant Acland’s Anatomy videos – these videos are beautiful prosections of very well-preserved cadavers (which are much more helpful, in my opinion, for understanding what the structures actually look like than studying from a dried-up cadaver).

Those are my primary study sources. I may occasionally glance through BRS Gross Anatomy or play around with this awesome (and free) 3D anatomy visualization website – one of the reasons it’s so great is that you can actually dissect away certain structures, which is awesome for getting a handle on three-dimensional relationships of otherwise hard-to-visualize structures.

One of the many things I like about Anki is that, in the days leading up to the test, I wasn’t spending time learning stuff. I already knew (or at least had seen) the structures we needed to know, because I had been reviewing them according to the spaced repetition algorithm on a daily basis. Instead, I was able to spend time doing the relevant written and practical exams on the University of Michigan Medical School’s website, which is an incredible (and, once again, free!) resource. It really helped tie certain concepts together in clinical scenarios, while at the same time giving me a rough idea of what the online practical format would be like (although, some of the pictures were rather frustratingly unclear…). I did make an effort to do a passive once-over my lecture notes, just to have one last integrated exposure to all of the material and also to review anything that I hadn’t deemed worthy of “Anki-fying.” Finally, I also reviewed any relevant sections of Rohen's Color Atlas of Anatomy to get an idea of what the beautiful illustrated pictures in Thieme and Lippincott actually look like in “real life.”

It was only the day before the test that I actually went down into the lab, which marks the second time I’ve been down there since anatomy started a few weeks ago (the first time was the dedication ceremony for the cadavers). While it can be enlightening to see first-hand what certain structures look like and how they interact with other structures, what you’re looking at in lab is not the best representation of what things look like in real life (Acland’s videos do a much better job, I think). Nevertheless, the anatomy lab is somewhat a rite of passage for medical students, and besides, these are the cadavers that most of the pictures for the practical are coming from. I spent maybe three or four hours in lab, reviewing stuff with other students as we quizzed each other. Some fourth years are also participating in the course as part of a fourth-year anatomy elective and also gave some great mini-reviews. Finally, we have what our professor calls “Magic Pens” (no idea what they are actually called) that are essentially electronic pens with speakers in them. You can tag a body part with a special tag, and the pen will read the tag and play back a recording of whatever the professor wanted to record about that body part. These were helpful for solo-review, since it can otherwise be frustrating trying to pick out various muscles, arteries, and nerves out of something that, a few weeks into the course, looks less like a human being and more like road kill.

One of the biggest challenges of anatomy is figuring out a study routine that works well for you. Each student will learn differently. Another one of the big challenges is sorting through the mountain of information presented to you, organizing it in a way that makes sense, and memorizing it. I feel like the tools above help me do that, and it seems to have paid off. I’ll continue using these resources for the next test, and hopefully things will continue to go ok. We shall see. Meanwhile, my dissection rotation is coming up – I get to do the thorax and abdomen, which should be interesting.

We start on Halloween – fitting, I suppose.

Friday, October 11, 2013

The Stare of Death

I’ve been on fall break for the past week…and it’s been glorious. Loyola starts a little early, but that translates into a week-long break halfway through the first semester. Which is most excellent – and much needed. It’s been a long few months. My wife and I have spent the break basically trying to be as non-productive as possible (i.e. watching a ton of old movies that we watched as kids, eating ice cream, and occasionally doing more big-person things like shopping, home repairs, etc.). We’ve had a blast.

We also got to go to our first ultrasound, which was awesome. My wife is twelve weeks along now, and he?/she? is starting to look like a little human being. It was quite the moment when we got to see our child moving around, kicking, and generally looking cute on the ultrasound screen. Just because I can’t resist, here’s one of the pictures we were given to take home with (awww....). His/her feet kind of look like claws in this view, actually. But they’re really quite normal – we checked. I may or may not have tried to count his/her fingers.

But, alas, break is soon going to be over, and back to the grind we go. We started anatomy a few weeks ago. It’s actually been really interesting, but it’s also been really, really busy. The tried-and-true fire hose analogy that people use to describe the volume of information coming down the pipe at you in medical school – all of which you have to know, and know well – continues to be proven true, if not even more so than before.

Loyola actually recently changed up their anatomy curriculum. Their overall goal was to cut down on required time slogging through excess adipose tissue in the lab and increase the time that students had to master the material on their own. Personally, I’m a fan of that goal. Dissection is an awesome experience, and somewhat of a rite of passage for doctors-in-training, but it can nevertheless be somewhat of a drain on one’s limited amount of time. So, instead of having close to twenty bodies for the class and everyone in the lab at once with only a few instructors to go around, they’ve cut the body number down to six, posted a faculty member at each table, and split the class up into rotations, with each rotation dissecting a certain region of the body. I was assigned to the thorax and abdomen, which should be interesting. Students can, by the way, go down whenever they want, but only absolutely have to be there during their rotation. Additionally, instead of making us sit in lecture, they’ve tried to summarize the key points of lectures in short-ish videos that we’re supposed to watch before coming to class (which, during anatomy, only goes for about an hour or two max – which has been awesome). During class, the idea was that we’d go over board-style questions that made us really think through the relevant material to arrive at an answer.

There have been a few glitches in the execution of their new curriculum, however. The biggest issue has been with the videos and “lectures.” Unfortunately, trying to pare down anatomy to a few “key points” leaves a lot missing. It’s difficult to then go forth and memorize crap when we really don’t know where to stop – we could, of course, go on memorizing forever (and, being the neurotic medical students that we all are, we would). We really didn’t know where to stop. Additionally, we were supposed to watch these videos the “night before” the “questions lecture,” which really gives us no time to process and learn the information…which means that the lectures really turned into a waste of time, since we had no idea what we were supposed to be doing. Finally, some people weren’t happy about the change in lab setup – I remember one of the questions that always seemed to come up in tours of the schools on interview day was something along the lines of “What’s your student-to-body ratio?” (As an aside…this really isn’t all that important. Really.)

Thankfully, Loyola is pretty responsive to its students. We had a Dean’s forum, where we basically were given free food and were able to ask the Dean of the school any questions that we had. Anatomy was a hot topic. We all expressed some of the above concerns, and within a few days we started to see some changes. First, the “question lectures” became more “lecture-ish.” This was actually the most helpful change, in my opinion, as it’s nice to have someone walk you through certain things that don’t come as easily from a short video or staring at a textbook. Next, the professor produced a more definite list of what we should focus on. Finally, for those students who wanted more lab time, the professor started doing short, daily reviews in the lab of the previous day’s dissection, just so we can see things on an actual human body instead of simply in pictures and to save us the pain of going down on our own and trying to pick through things. So far, I think things are shaping up for the better – we’ll see how things go.

I have had a few opportunities to get out of the classroom, though. One of the things I did was volunteer at a free clinic in Chicago that Loyola students basically take over for one night a week. First year medical students essentially observe, might take a history, and pretend to listen to heart and lung sounds. Second year medical students, on the other hand, really get to run the show – they’ll interview the patient, examine them, come up with a plan of treatment, present the case to an attending, talk it through with them, and write a note. It’s really a great opportunity to get out of class and use some of the skills we are learning. So far, first years have only covered the patient interview and spent some time interviewing standardized patients, but as the year progresses we’ll learn more physical exam skills. That should be fun, and the clinic should be a great place to practice and take a break from class.

Loyola’s anesthesiology interest group also has a program called APEP, or Anesthesiology Preceptorship Enrichment Program. It’s essentially a program that pairs students up with an anesthesiologist mentor with whom they meet once a month for a few hours during the anesthesiologist’s shift and discuss some basic science concepts in the operating room. It’s a great way to translate some of our bookwork to the real world. I’ve met with my preceptor once so far, and had a great time. We talked about different sedation methods, intubation, difficult airways – and there was mention of a possible opportunity to intubate in the near future. That’d be fun. The program isn’t just for students interested in anesthesiology. I personally didn’t have a huge interest in it coming in to medical school, but I do want to explore different specialties and see what’s out there. Also, it’s a great opportunity to spend some time in the hospital and learn some practical stuff that one might not get through a lecture.

Finally, I was able to spend an afternoon shadowing an emergency physician. Since I worked for a few years in or around an emergency department before medical school, and this is the specialty I have had the most exposure to, it’s also the specialty I’m most interested in at this point (supposedly, I’m supposed to change my mind about this at least twelve-bazillion times in the first couple years. Or so I’m told. I’m sure I probably will). It was a good shift – it’s different being introduced as a medical student and getting the opportunity to participate more in the patient’s care. As a scribe, I was used to standing in the corner and writing down what was going on. Now, I actually get play some small role, and that’s a lot of fun.

About halfway through the shift, we heard the EMS radio come on. Through the static, we gathered that there was a full code about to come through the door. The usual calm before the storm ensued – people began to prepare one of the trauma rooms and gather around the stretcher, double-checking their equipment and wrestling their uncooperative gloves onto their hands. Then the double doors to the ED flew open and a stretcher came through. It was being guided by two people with another person trying their best to continue chest compressions while walking alongside the stretcher. I didn’t catch most of the story, although it didn’t sound like there was much of one – male in his mid-sixties, found down. CPR started at the scene, epinephrine given just outside the ED doors, no response.

The doctor I was shadowing didn’t have this patient, but followed the stretcher into the room to see if the other doctor on wanted a hand. My scribe instincts kicked in, and I started to look for a corner to stand in and stay out of the way. Before I found one, though, she motioned me to follow her in and threw me a pair of gloves. The poor soul who had walked in beside the stretcher doing compressions had been relieved by fourth year medical student who was rotating through the ED, but he was starting to look a bit fatigued. Before I knew it, I was standing over a very dead-looking patient, bouncing up and down on his chest, and trying to keep time to “Stayin’Alive” in my head.

This was my first time doing CPR on a real person. The first thing that struck me was how everything seemed to slow down a bit. There was plenty of time to think. The second thing that struck me was how grey the fellow looked. After that, I was surprised by how “rubbery” his chest felt – somehow, I didn’t expect the rib cage to have that much rebound. Finally, I quickly started thinking that I really should do more cardio – compressions are exhausting!

The doctors did a great job of making it a teaching experience. They showed me and the other students where to check for a pulse to make sure that the compressions are effective, and after using ultrasound to check for cardiac activity, walked us through what they were looking for and what showed up on the ultrasound. It was really interesting. They also made sure I saw the “fixed and dilated pupils” – the stare of death. That was…weird. It really was a truly empty gaze. With cadavers, their eyes are usually closed. It was different staring into the eyes of a person who, moments ago, might have been thinking about what they were going to eat for dinner that night.

The gentleman didn’t make it. Or, more correctly, he stayed dead. And life went on. We went and saw another patient, the body was prepared for viewing, and…that was it. I had seen people die before, but this was the first time I had really been involved in their care. That said, it really wasn’t sad so much as it was more of a profound moment. I wonder if that feeling will stick around.

Medical school continues to be a blast. This week off has been awesome, and I wish that it didn’t end in a couple of days, but at least the material we are learning is, I think, really interesting and fairly relevant to our future careers. So, back to the grind we go.