A Terrible Day at the VA

Oh. My. Gosh. What a day.

For our Patient-Centered Medicine course, we are paired with a physician and an M3 student mentor, both of whom we have to shadow a couple of times over this semester. Since my wife is due in April, I figured it’d be best to get those out of the way now. So, today, I shadowed my M3 mentor. He was on an inpatient psych rotation at the VA hospital near Loyola. Which is probably the most terrible place in the world (ok, not really, but the events of today have left me rather ill-disposed towards it at the moment…).

After navigating my way to the main entrance, where I was supposed to meet my mentor, I discovered that, as it turns out, there are actually two main entrances. On opposite sides of the freaking building. So, I continued to navigate my way into the bowels of the VA and eventually found where I was supposed to be. I met up with my mentor, and he took me to a little psych consult room where a couple of other junior/senior medical students were working on stuff. After reviewing the past history of the patient we were about to go interview, we went and found the psychiatrist (whom we’ll call Dr. J) my mentor was working with and my mentor introduced me to him. He seemed nice enough, perhaps a little eccentric. We started walking back through the maze of hallways while talking about the next case. Dr. J asked if I had been here before, and I said no. They both smirked – in a friendly, yet knowing way – and said, almost in unison, “Welcome to the VA.”

Huh.

As we were nearing the elevators, Dr. J turned back to me and said, “You’re welcome to take the elevators, but we take the stairs. We’re going to the 8th floor.”

Of course you are.

I went along with it though, like a good little medical student. After we huffed and puffed our way up to the 8th floor (I really need to do more cardio…) we stopped at the nurse’s station. “We always catch our breath before going into a patient’s room,” Dr. J said, in between breaths.

After recovering there for a bit, we finally knocked on the patient’s room. He was a male in his mid-thirties who was, at the end of the day, a pretty normal guy. He had had a tough few years, though, with family members dying, a divorce, and some tough luck. He had apparently had some chest pain recently (which he had experienced before) and presented to the VA seeking help. They had started to rule out a cardiac etiology, though they still wanted to do a stress test. Dr. J was here to investigate the possibility of generalized anxiety disorder and/or panic attacks causing his symptoms.

In the emergency department, where I worked for two years before medical school, a “long” interview was maybe 15-20 minutes. Today, though, we spent almost an hour interviewing and talking about the patient, which my mentor said was fairly average. We sorted out how best to get him some help in the form of outpatient counseling and a little Ativan for the odd anxiety attack, and went on our way to check on another patient, who was on the second floor. This time, mercifully, we took the elevator. This patient was in surgical ICU while recovering from abdominal surgery. He had apparently been a bit delirious, mostly at night. Last night, he had ripped out his ostomy bag, making a mess. He also apparently was telling people that he was actually dead and didn’t know how he was talking to them.

Today, though, he seemed mostly normal. Mostly. In talking to him, you could tell all of his oars weren’t in the water, so to speak, but he had apparently decided that he was in fact alive now. That’s good. But we’ll keep you here just a little longer. And give you something to sleep at night.

After that, I headed out. I had a bunch of stuff on my plate to do that afternoon, mostly in the form of actual school work I needed to get through. Before I left the VA campus, though, I wanted to pick up my ID card that had taken forever to sort out. Back when we first started, we had to fill out an hours-long set of forms online for a background check and then get fingerprinted (which took hours and hours of waiting in line at the ever-so-efficient VA HR department) so we could get a government-issued ID for our rotations at the VA hospital in third year.

Turns out, though, the person in charge of handling the paperwork for my entire class left the VA while it was processing, and somehow all of our applications were forgotten about. And after sitting in some electronic holding vat for too long, the VA system terminated some of ours, depending on how long they had been sitting there. Those of us who had gotten them done early, for example. Like me.  And, by the time they told us, our original fingerprints had expired. Lovely.

So I had gone back to HR a few weeks ago to get my fingerprints redone, and tried to figure out what was going on with the online forms. Someone took my name and said they’d figure it out and get back to me.

Which never happened.

I ended up calling the person in charge of “endorsing” us for our badges, who said don’t worry about it, we really didn't need that form anyway (so we spent hours filling it out then because…?). Your fingerprints are all you need for the background check. Go get your card.

Awesome. So, finally having a free moment from school, I thought that I’d run over to the ID card office and pick it up real quick. Hahahahahaha……

Turns out the office is in the middle of a seemingly mile-long building that stretches across the entire VA campus. And looks like it’s abandoned. And only has one entrance (that I could find) labeled “Suite C.”  I needed Suite E. I couldn't tell where along the mile-long expanse to park, so I called the office number and asked them for some type of landmark. “We’re in building 1.”

Yeah, I got that.

“Oh, we’re at the north side of the building.” Great. So I drove to the north side of the campus/building…no entrance. The frick.

Drove back to Suite C. Parked. Went in. Was told to walk up a long hallway to Suite E. So I did, and finally found the office. Then I found out I wasn’t actually going to be able to pick up my badge, I actually needed to start the process. Which means more fingerprints and pictures. Buuuut the fingerprint machine wasn’t working – its server is busy. Can you use the extensive fingerprinting that I had completed at HR? No, our systems aren’t connected like that. Fine. Let’s try again. And again. And again. Let’s wait and see if the system suddenly becomes not busy. I did some Anki while waiting. Try again. Wait again. More Anki. Try again. Wait again. Try again. Oh, let’s change this parameter – great, it’s fixed (an hour and a half later). Oh, remember those online forms you were told you didn't need? You actually do need it. We can’t give you a badge. Sorry.

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So I walked back out of the building, toyed with going home and just doing the stuff I needed to get done, but decided that I’d better just go over to HR and sort out the online forms thing now and save myself a trip back to this dreadful place. So I walked over to HR, and actually ended up speaking to a lady there who was actually very helpful, which was a nice change of pace. She even stayed a little over her shift to sort things out, revived my forms from their electronic grave, dug some of my old paper forms that I had signed months ago out of some stack in a corner so I didn't have to go through them again, and got things moving again. I should be able to finally get my ID card in a few days.

I hope.

Frostbite

Anatomy is finally over.

Actually, it’s been over for about a month now. We finished the week before Christmas, and then went on a two-week break. Glorious break.

My wife and I flew home for Christmas to the West Coast (the best coast, in my humble opinion…) to spend it with our families. The flight there and the time we spent with them was pleasantly uneventful and relaxing. Then the effects of a so-called polar vortex hit the Midwest, wreaking havoc with our travel plans.

Image politely stolen from here

We were supposed to return home on an early-morning Friday flight. We pre-packed our stuff the night before, woke up at the rather ungodly hour of around 3 am, made our way to the airport, got our bags inside, made it half-way through the line to check our bags in… and then one of the airline employees made her way towards the line and started calling out, “If you are flying to Chicago, Denver, or New York, your flight has been cancelled due to weather. Please call the 1-800 number to reschedule.”

Well, darn.

I dialed the number while we were standing in line – the first of many times we would call this number over the next few days, as we would soon find out. I was answered by a machine and quickly put into an ever-growing queue.  My wife tried calling as well, and actually ended up getting through first. We were able to reschedule, but due to the treacherous weather our destination was experiencing, the earliest flight we could get on wasn’t till Sunday.

So we hung out for a few more days – sort of a forced vacation. At least we were able to be with family, but we were both ready to get home. On Sunday morning, we repeated our get-up-way-too-early-get-to-the-airport-get-in-line-check-to-see-if-the-flight-is-canceled-for-the-upteenth-time routine. We checked in, checked the flight status board on the way to security, made it through security, and were walking to our gate when we checked one of the flight status boards again, just to be sure.

Cancelled. Again.

We walked down to the gate just to see what was going on – the flight had literally been cancelled in the time it took for us to walk through security. This time we had to somehow get our baggage back, and apparently the airline didn’t have any standard procedure for this – one of the airline employees literally took a vote among the would-be passengers that were present at the gate about how they wanted their baggage returned (they ended up carting it to some office somewhere in the airport where we could go pick it up).

We again tried calling the 1-800 number, and when we finally got through, the earliest we could be rescheduled for was Wednesday afternoon – three days away. Argh. Also, it turns out the airline we were flying on was the one airline that wasn’t able to put their passengers on the flights of other airlines in case of situations like this.

By this point, we just wanted to get home. We found a place with WiFi access, took out one of our laptops, and searched for the soonest flight heading back home on another airline. We would have pay a bit more to switch our tickets, but whatever. We wanted to get back. We made the switch, but now we had to figure out how to get our baggage. It turns out that, normally, if you made a last-minute switch between airlines like this when you were already past security, the airlines will just switch your baggage for you as well. But the airline we were flying originally was, of course, the one airline that didn’t do this. So, we walked back out, tracked down our baggage, got back in line to check in our bags, went through security – again – and finally arrived at our new gate, tired and slightly ruffled but happy to be finally heading home.

Of course, this is all still at around 6 or 7 am in the morning. Our new flight didn't leave till around 10 am, so we had a few hours to kill. We hung out, got some food, read, and waited. Around 9:30, we were told that our flight would be delayed for another hour. Ok, fine. We just wanted to get home at some point.

We waited around some more, and as the promised time drew near, another announcement was made: we were delayed again. We ended up being delayed four times, but after spending about nine hours in the airport we finally were able to board the plane and make it home. Just in time for record-breaking subzero temperatures. At least school was cancelled that Monday, which was nice.

Our first day back, it was around -15 degrees Fahrenheit with a wind chill of around -30 to -40 degrees. We, of course, didn't get the memo and decided that we should go shopping before the week started. That was fun – particularly the part where I almost lost a couple of fingers (ok, not really, but I definitely reached the early stages of frostbite…) trying to uncover our buried cars, one of which didn't even start up for a couple of days (till it warmed up – relatively speaking – to around 25 degrees, anyway…). We had a pipe freeze, too, which thankfully didn't burst. That would have been a bummer.

School started up again that Tuesday. We started our physiology class, which will run for the rest of the semester. Now (a little over two weeks later), we've just finished our cardiac physiology section, which was really quite interesting. It’s quite the organ. We also learned how to interpret EKGs, and it’s amazing how much information can be derived from all of those bumps and squiggles. We also took our own EKGs, and apparently my heart is actually pointing almost straight down in my chest – most people’s hearts point down, left, and towards the front. The things we learn in medical school.

Oh, and apparently we have another cold front coming in tomorrow. Chicago, we love you too.

My Personal Statement

Note: One of the more time-consuming and difficult things you must complete for your medical school application is a personal statement. It essentially provides an opportunity for you to tell admission committees who you are, what you value, why you want to be a doctor, what makes you different from the thousands of other applications, and anything else that doesn't really fit into the tidy little boxes on your AMCAS application. It’s an important part of the application for all schools, and a crucial part for some. Outside of your transcripts and whatnot, this is your only chance to convince the school to consider you for an interview.

I briefly wrote about how to formulate a personal statement here in the “How to Get into Medical School” series. One of the more difficult parts of writing it, for me, was not really knowing what it was even supposed to look like as a finished product. With that in mind, I've decided to post mine here – not that this is the only way to do it, by any means, but it’s one way. Whatever you end up writing, you'll most likely think it's the most amazing thing at the time, only to cringe when you look at it several years later (little heavy on the melodrama in mine, I think...). Regardless, I hope that it might help point some of you who are trying to compose your PS in the right direction. Good luck.

Death was no stranger to me. But this one was different--I knew her.  I was working in the patient transport department in a large hospital in Portland. I was new, and only had been working for about a month and a half. It was the middle of a moderately busy Friday evening shift. I sat down to rest my weary feet and to pick up a new job over the phone system. An automated voice came on the line, telling me to take a patient named Katie from the seventh floor to the morgue. My heart sank. I knew this woman. I had recently transported her, and even though she was in the hospital and obviously sick, she hadn't struck me as someone who was on death's doorstep. She was young--not even forty.  Yet here I was, picking up her morgue job. I hung up and reached for the morgue key.  The key was attached to a trapeze handle, apparently to make it easy to find. Most of the trapeze handles in the hospital were bright colors. This one was black. Fitting, I suppose. I left the transportation office, obtained a gurney and a blue tarp to place over the former patient, and began the long walk to the seventh floor of the hospital.  The seventh floor, by the way, was the Oncology unit. Katie had died of cancer.

Death hadn't really bothered me until Katie. But Katie was different. Cancer had struck her down when she had so much life left. And even though I had not really known her, I had cared for Katie and talked with her. She had, to me, been a real person, while the cadavers in anatomy lab and bodies of other patients had been anonymous. They had lived their lives, of course, but I had not been a part of that. With Katie, I had. Who could have known, on that day that I transported her just a few weeks ago, that I would later wheel her dead body to the hospital morgue? Sorry, Katie. We have failed you. Cancer has won this battle.

This was not the first time I had encountered this sense of helplessness.  A few years before Katie, I had the opportunity to travel to Africa.  While I was there, I was mentally wrestling with myself about the future.  When I was younger, I thought I would go into law.  The idea of being presented with an issue, thinking through all aspects and perspectives, and then using logic and argument to debate for one side appealed to me.  The thrill of the contest seemed to provide a rush like nothing else. However, in my first college English class, we were assigned to write the quotidian research paper.  I chose to focus on the medico-legal aspects of stem cells.  Although here again I found the excitement of laying out all sides and making my case, there was something new here.  The potential capabilities of stem cell applications in particular, and medicine in general, contained within themselves the possibility not only of captivating intellectual opportunities, but the real ability to radically change people's lives in a tangible way. It was then that this usurper of my attention, medicine, entered into my life.  I knew it had the potential to cause change, and in Africa, I saw the great need for just that. We spent some time in Kibera, the second largest slum in Africa. People were living in huts built from sticks and mud. Hygiene was poor--walking along the narrow roads between huts, it was generally best to not dwell on what was underfoot.  There was no running water, no formal sewage system. Disease, including HIV/AIDS, was widespread. Change was needed here.  These people needed social help, political help, economic help--but first, they deserve at least to live.  To not be plagued daily by easily preventable diseases. Medicine was necessary for this to become reality, to begin to effect lasting change--and I deeply desire to play a part in this.

A year later, I was working as a lifeguard back in the United States.  It was here that I experienced a rudimentary exposure to medical care, particularly emergency medicine.  The thrill I thought I had found in simple debate was exponentially replaced by the high that came from being presented with an acute problem, whether a simple injury or a drowning patron, accounting for a number of factors that play into the situation, and responding in a way that effected, often, a measurable relief.  I thoroughly enjoyed it.  To further explore this, I volunteered in a local emergency room, became trained as an EMT, and worked as an ED Scribe. The more I traveled into the realm of medicine, the more hooked I became.  But in all these positions, the limited level of care I was able to provide bothered me.  I wanted to be able to do more for those I cared for.

The majesty and brokenness of our inner workings have always intrigued me.  But what was crystallized for me in these experiences was a deepening of my desire for change; an urge to take up the weapons of medicine and join in this bittersweet war between life and death--the ultimate debate.  Death is sometimes an ally, but all too often an enemy. I want to fight for those like Katie, for those who live in Kibera, and for those whom Death strives to take too soon after they have lived lives of despair. This is a war that must be fought on many fronts, but one that I desire to fight as a doctor.

How to Study in Medical School

In an older post, I wrote a little bit about my search for efficient study tools for medical school, and how I eventually discovered Anki and OneNote. To briefly summarize, I spent part of the summer before school started trying to figure out how I was going to study. I knew it would be a different ballgame than undergrad (and that turned out to be true), so I figured my old methods wouldn't work so well (which would also be true...). In undergrad, I usually just went to class, took notes in a binder, read any assigned reading, and reviewed everything once or twice in the day or two before the exam, depending on the class. For medical school, though, I knew that I would need a way to take in more information, organize it, and review it more than once or twice.

After poking around the internet a bit, I settled on Microsoft’s OneNote to take notes (if you have a PC, I highly recommend this program. If you have a Mac, I don't think it's available. I have heard good things about Evernote, though, which is available on both platforms. That said, I prefer the organizational structure of OneNote over Evernote – both are good programs, however). This was a great way to 1) cut down on what I actually had to lug around 2) organize everything in one searchable, legible database (this latter point is important, as my handwriting is chicken-scratch) 3) and take more notes much more quickly than I could write them, while also incorporating various media as needed.

Below is a great video describing how one can use OneNote in medical school. Everyone might do things slightly differently, but this provides a good starting point. 

Note: These aren't my videos, but I think they give a great overview of how to use OneNote and Anki.

If you have a Mac, then I’d suggest checking out Evernote. Click here for a basic overview of how to navigate Evernote.

If you used paper in undergrad, like I did, you might think that you’d rather just keep doing that. And that’s fine. But if you can, I’d really recommend switching to a computer-based note-taking program. I have found it to be much faster and more efficient. It allows me to pretty much have access to every note that I have taken at all times, search the entire database, and sync it all in “the cloud” so that, if I were to lose my laptop, I could be up and running on any other computer in the time that it takes me to log in to SkyDrive. OneNote’s built in screen-capture feature is also a very helpful tool that I use on a daily basis.

So I had a good way of taking notes. Great. But how would I review them? It is a common refrain among medical students that you can expect to forget pretty much everything you learn in the first couple of years. That may be true, but that didn’t sit well with me. I’m sure most of what we learn is irrelevant, and that’s fine, but not all of it is, and a large chunk of what we are learning we’ll have to know for the boards. So I started to wonder if there was a way around that…and found Anki.

Anki is essentially a free flashcard program. You create the cards, review them, and then the program will use a spaced-repetition algorithm that makes certain cards due at various intervals, depending on how well you could recall the information. (Update: I've written a brief Anki Q&A here.)

So, for example, you make a card. Right after making the card, you review it. It’s pretty easy, and you answer it correctly. The next day, the card is due again. Again, you answered it pretty easily, so when Anki gives you the option of choosing how well you recalled the information (generally something along the lines of “again,” “hard,” “good,” or “easy,” with each option being associated with a certain default time interval, like “10 minutes,” “2 days,” “3 days,” or “4 days,” respectively), you select “good.” In three days, the card becomes due again. If you again select "good," this time the time interval might be “5 days,” and so on and so forth.

Taken from this random website

You can see in the graph how this works out over the long term. After we learn something, that knowledge immediately begins to decay. However, we can slow that knowledge decay by exposing ourselves to that information again within a specified window of time. Over time, this spaced review strengthens the memory of whatever it is we are trying to recall. Sounds great… but the trick is to figure out when we need to review the information. With physical flashcards, this quickly becomes tedious (especially when you accumulate thousands of flashcards...). With notes, we might review those a few times before a test, but then probably never really look at them again. With Anki, you don’t even have to think about it. Anki does all of the work, and uses your answers (whether the card is hard, good, or easy, for example) to create a personalized scheduling algorithm for you.

So how do you use this in school? There are many different ways to use it, but I’ll briefly walk through how I’ve been using it. After lecture, I review my notes and find important concepts, ideas, or minutia that I feel I need to know. It’s important here to distinguish between things that only the professor would ever ask, things that you might actually need to know for boards, and things that you simply find interesting and/or helpful. For the most part, you only want to make cards for things that fall into the last two categories. That said, you can make cards for things in the first category and “suspend” them after the test – that way, you reap the benefit, at least in the short term, of spaced repetition while avoiding making your daily reviews in the long term too long.

I would recommend trying to only make 20-50 cards a day (ideally), with an upper limit of 100 new cards per day. When making new cards, there are some rules that you should keep in mind about how to make efficient cards – you can (and should) read them here. If the cards that you make are junk, then Anki will not be beneficial for you. Right after you make the cards, be sure to review them. Additionally, it can be helpful to tag the cards as you make them – so, for example, if you are making cards about the upper extremity in anatomy, you can tag them all under “upper_extremity” so that you could pull all of those cards out later for a dedicated review, if you so desired. You can also tag by source – for example, if you wanted to check what you are learning in your classes against a gold-standard source like First Aid, you can tag any info that is in First Aid with an appropriate tag so that you can review it later or just to remind you not to suspend that card down the road. Again, while it would normally be a waste of time to look at a source like First Aid in your first year, with Anki this is no longer true, because you will actually remember the information. Ideally, this will help you later when you do begin to study for boards.

There are also different types of cards you can make. You can make straight flashcards (e.g. prompt on front, answer on back), you can use something called cloze deletions, or you can use image occlusions. There are many other types of cards, but these are the three types that I primarily use.

Cloze deletion and image occlusion are powerful tools, and are perhaps best illustrated by video. So below are some relevant videos that provide a short introduction to how to use Anki and create those types of cards. I highly recommend taking the time to watch them.

Now you’re ready to get started. Go here to download Anki, and here to see the user manual if you have any other questions – although, if you’ve watched the above videos, you should have a pretty good handle on things.

Finally, if you ever have any problems with Anki, following the instructions in the video below should fix them.

 

Once you’ve made the cards, make it a point to review them daily. Just get it done – you’ll be glad you did later. It might take a little more time up front to create the cards and spend time reviewing them, but when it comes time for a test, I think you’ll find that you’re a bit less stressed about it and are able to spend less time trying to cram information in your head. Usually for tests I just passively review my old notes once – quickly – just to get a “big picture” review and to go over anything I specifically marked as something I should review (for example, if I didn’t put something in Anki because it is important for the test but for absolutely nothing else in life).

Also, reviewing them can be done on the go. There is an Anki app for both Android (free) and iPhone (not free, but worth it). For example, I start reviewing cards in the morning while eating breakfast, while walking from the parking garage to school (which would otherwise be a waste of 5-10 minutes, and during which time I can get through a bunch of cards), in between classes, etc. This allows me to sometimes be completely finished with my daily review by the time I get home, or at least have a significant portion of it knocked out.

So that’s OneNote and Anki. These are very powerful tools. There are, of course, many ways to get through medical school, but, at least for me, these programs have single-handedly gotten me this far, and I plan on continuing to use them throughout the rest of school.  

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.

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.