Inside Med School

Have you ever wondered what a breast implant looks like after it’s been in your body for a while?

The body has a pretty amazing immune response to a breast implant, which is to treat it as a foreign object. The body’s immune system will form a capsule of collagen fibers around the implant, to wall it off from the rest of the body. This is an example of an implant from a 70+ year old woman. It’s interesting because it is one of the earlier silicone-filled implants which are no longer used today, and it’s also very interesting to see the capsule up close.  Pretty cool huh.

Today was my first exam in Gross anatomy, and it went very well. The exam covered the back and upper limb. If you would have asked me 3 weeks ago I would have told you there is no way I’ll be able to cover all the material we covered for this exam. Not to mention that at first glance the structures look totally different in real life than they do in the textbook. Take the brachial plexus (a bundle of nerves extending from the neck to the armpit region) for example. The picture on the top shows you what it should look like, and the picture on the bottom is more like what it actually looks like. At first glance it just looks like one big tangled mess. But now that it’s over, I can’t believe it but somewhere along the way I learned all the anatomical structures of the back and upper limb, and the picture on the right looks totally different to me now. By the time this test came around, I was flying through the questions, which is pretty exciting in its self because I was actually freaking about this test only a few days ago.

So before I continue let me describe the exam. It had two components a written, and a practical component. I started with the practical exam, which I thought was kind of fun. Basically, the professors set up the lab by using every group’s cadaver to identify a structure. The structure would be highlighted either by a string around the structure, or a pin through it, and it was our job to identify it. We were given 1 minute to identify the structure, then a buzzer would sound and we would have to move to the next cadaver. Along with the cadavers, was a table with a bunch of bones on it (Bone row.) For bone row, there were several questions asking to identify the bone, structures on the bone, or muscles and ligaments that attach to specific sites on the bone. There were also a several questions from radiographs (X-rays, CT scans, MRIs) that asked us to identify structures on the image, or locate injuries and what structures would be affected by the injuries from the radiograph.

Over the past couple weeks I spent a lot of time in the lab and became pretty familiar with all the bodies because there is a lot of variation among the different bodies, and a lot of the time the structures look a lot different in real life than they do in the textbooks. Our professor was very fair about using clear examples, examples from cadavers that had a deviation or anomaly. I guess that gets us prepared for real life. I found that with anatomy it helped a lot that I spent so much time in the lab with the actual bodies as opposed to studying from a textbook because there is a pretty significant spatial aspect to anatomy. Textbooks usually present all the muscles and nerves in anatomical position (lying on the back with the palms facing up.) However, a lot of structures look very different from different angles and when the body is in different positions. So it helps to be able to orient structures with respect to other structures. That is very important skill to develop because the structures are presented in different positions and you have to be able to orient yourself pretty quickly to do well.

So after all the studying I did, I found that I was identifying the structures almost instantly. There were a few where I had to stop and spatially orient myself, but nothing I haven’t encountered before. Midway through the exam I was impressed by how easily I was remembering all the structures and was kind of enjoying the test.

After that was over, I took the written portion of the exam. By written I mean multiple-choice questions. The written portion sort of contextualizes everything. While the practical was more about rote memorization and spatial memory, the written tests the important clinical concepts associated with the anatomy. So for example a typical questions would ask something like:

A man comes in with a stab wound to the lateral side of the thorax. As a result, his scapula protrudes posteriorly (winged scapula.) Which nerve did he damage?

So to answer that you would have to know that the long thoracic nerve innervates the serratus anterior muscle, which is attached to your scapula and pulls it close to your body. So if you cut that nerve, it disables that muscle causing the scapula to stick out because that muscle can no longer hold it in place. So for this written exam the bulk of it tested our understanding of nerves and blood vessels and where they go and which muscles they affect. We also had to know where different muscles are attached and what motions they cause.

As I expected, anatomy was the class I was most excited for coming into med-school and it still is. I really like this class. But for the next two weeks were taking a break from anatomy and it’s back to the books. In two weeks we have 3 day test covering biochem, physio, micro-anatomy, behavioral sciences, genetics, and nutrition.

Let me start by saying the first cut in anatomy is a pretty memorable experience. It’s kind of a monumental period in a career in medicine. Our first lab was titled “Dissection of the Back,” Pretty straightforward. So my first incision was a shallow incision from the back of the neck down the spine towards the lumbar region. Making that incision marked the beginning of anatomy and it gave me goosebumps while I was doing it. From then on my lab partners and I made some transverse cuts perpendicular to that first cut and started to remove the skin off her (the cadaver’s) back. That process was a little frustrating because we were all very eager to see all the muscles in the back but skinning the back was taking a lot longer than we thought it would. It’s more tedious to remove skin from a cadaver with a lot of subcutaneous fat, and the groups who had skinny cadavers were just flying through this process and exposed their muscles with ease.  It also was taking a while because we weren’t sure how deep to cut under the skin because our cadaver had a lot of bruising and we weren’t sure if we were still in fat, or if we were cutting into muscle. Another thing that surprised me was how tough skin is. To pull back the skin they advised us to make a slit in the flaps we created, stick our fingers in it and use it to pull back on the skin while we use the scalpel to cut the connective tissue holding it down. I was surprised how tough the skin was, because by the end of it I was really pulling hard on that skin to get more tension and the initial slit I made stayed about the same size.

Any ways, eventually we removed the skin and reflected the flaps out of the way so we could start observing the muscles.  So at first I thought it was a little overwhelming to have our first lab be the entire back. However, once we exposed it I could see why they wanted us to start from here. The muscles in the back are pretty big, and there aren’t that many of them so it’s a great place for beginners to start because you don’t have to be that delicate. I think a lot of people would be familiar with the superficial muscles of the back especially if you like to lift weights. So it was nice to see them up close. I remember thinking they were a lot thinner than I thought they would be. After we identified all the shallow muscles, we cut them from their attachments to the spine and reflected them back to reveal the muscles underneath, and observe the nerves that innervate them.

Once we looked at all the shallow and deep muscles we got down to the fun part, exposing the spinal chord! So to expose the spinal chord you have to cut away a section of muscle around several vertebrae in the back. Then you have to remove the spinous process of the vertebrae (the part that sticks directly out, you can feel them when you rub your fingers down your spine.) To remove the spinous process you have to use a hammer and chisel! It was pretty crazy because earlier I was being very delicate and trying not to cut any muscle tissue, then a few minutes later we cut away a chunk of muscle and were using chisels to crack open bone! It’s a pretty quick transition. Any ways once you chisel away the top portion of the vertebrae you can pull them off to reveal the spinal chord. From there we cut the dura matter, which is a sac that covers the cord, and exposed the actual spinal chord and the nerves that extend out of it and throughout the body. It was pretty amazing to see it up close and personal. We exposed a section of the spine from the 12^th thoracic vertebrae to about the 4^th Lumbar vertebra. That’s about the region where the spinal chord ends (it ends at about Lumbar vertebra 1-2.) Long nerves that extend down to the lower vertebrae innervate the rest of the back. A fun fact is that usually spinal taps or epidural needles are given at the location of lumbar 4 to avoid accidently puncturing the spinal chord. Also getting a gunshot wound below L1 is better than anywhere above it because the bullet will pass below the spinal chord and you have less chance of paralysis. That’s about it for our first lab. For a recap , we skinned the back, observed several layers of muscles, identified some nerves, and exposed the spinal chord. Pretty cool, for our first lab huh? I’m going to study a little now, and then fill you in on some more highlights from anatomy during my next break. Stay tuned!

First off, I’m sorry I haven’t posted in a while. I’ve been kind of busy lately, and put the blog on the backburner. Ever since my last post, my ex-girlfriend ( I’ll have to explain that later) came to visit me for a week and I spent most of my free time with her. Consequently she visited during our first week of dissection, so a lot of exciting things have happened since my last post. But now that she flew back to California, and I finished playing catch up for a series of exams which are now out of the way, I should have some time to get back into a regular schedule of posts. Thanks for bearing with me.

I would have to say that Gross Anatomy is the class I’ve been looking forward too most. It’s going to be amazing to get up close and personal with all the organs of the body and see how they are all interconnected. However, along with the excitement of what I’m going to learn, there is also a natural sense of anxiety over the fact that I’m going to be cutting open a dead body. It’s a strange concept to think about, because the people who have donated their bodies have given us a tremendous gift. They have donated their bodies to educate a new generation of physicians who can in turn save many more lives. It’s a beautiful circle of life if you think about it. But at the same time it’s difficult to deal with the mixed emotions. One of my good friends, who is now a third year medical student told me that the first day of anatomy he actually passed out, and that mad eme nervous because he is a pretty tough guy. So I figured if someone like him could faint, I’m sure it could happen to me. And I definitely didn’t want to be one of the people who faint.

So yesterday, we had our first lab, and actually met our cadavers. As we all entered the lab, there was a mood of nervous excitement in the room. Each cadaver is assigned to a group of five medical students. So my group members and I gathered around our dissection table, and there it was…our cadaver. While I was listening for the instructions I couldn’t help but think that this moment has finally come and the only thing holding me back from meeting my cadaver was a big blue tarp. So after receiving a brief introduction to the lab and where all the tools and resources are, we were all allowed to remove our tarps. So I pulled out the scissors and started to cut open the tarp and there she was! While I was cutting through the tarp I almost didn’t want to look, but I couldn’t help it and the first thing I saw was her face. I told myself that I would try not to look at the face until I got more comfortable, because I was afraid looking at the face would humanize the cadaver too much. However, to be honest, it was actually a kind of anticlimactic moment. It was exciting to meet the cadaver, but I wasn’t that shocked. In fact I couldn’t help but think that the cadaver looked kind of fake. It sounds kind of inhumane and insensitive but the fact that the body had a yellowish tint to it (most likely from the preservation process) made it a lot easier to handle the situation. I think it was a similar situation for everyone else in my group because we all sort of let out a sigh of relief after seeing the body. We even gave her a name. Well I didn’t want to because I think that is disrespectful, but actually a lot of people name their cadaver and I really do think it helps people become more comfortable around the cadavers. I know personally, I don’t really want to know about the story of the woman’s life or anything of that humanizes the cadaver until I’m done with the class. And if that’s the case for others, I can see how naming the cadaver can help distract people and sort of give the cadaver an alternate identity while we have to dissect the body.

So for this particular lab, we didn’t have to perform a dissection. We just had to unveil the bodies, clean up the bodies with a sponge bath, and then evaluate the bodies for things like scars, lesions, trauma, and protrusions that could indicate medical devices. First thing I noticed was that there were a few tubes sticking out of her legs, which are apparently for drainage purposes. Other than that we found some scars on her shins. After that we all had to work together to lift the body up and turn it over so we could clean the back and inspect it. Lifting up the body kind of reminded me that we were dealing with a real body because it was a lot heavier than I thought it would be. Once we flipped her onto her stomach, I had to lift her up a little and pull her arm out from under her body because it got stuck. Pulling out that cold dead arm was definitely a surreal experience that I won’t be forgetting anytime soon.

So over-all it wasn’t that bad. I think that getting a chance to meet the cadaver without actually doing a dissection makes it a little easier to transition into our first dissection. Speaking of which our first dissection is tomorrow! I’m really excited for that. One of the rules about anatomy lab is that the professors are there for any questions we may have. However, the one question that is absolutely not allowed is, “ what are we supposed to do today?” Basically what that means is that we have to do a lot of preparation before each lab in order to know what we’re supposed to do. Fortunately, reading the dissection manual and looking up all the structures in the anatomy atlas made me really excited for tomorrow’s lab. I can’t wait to make my first cut and observe the muscles and nerves I’ve been studying hands on.

Since my last post, I’ve had several exams, which ended this past Friday. Studying for them was pretty intense so it was good to have a short hiatus from school work this past weekend. One of the exams was a lab practical for histology. Which was really interesting. For the practical, there were 45 stations set up. Each station was either a microscope set up with a pre-focused slide, an electron micrograph, or an unfocused slide. The focused slides were projected on a monitor and a particular structure was circled on the monitor and we had to identify the structure and classify the tissue. Same idea for the electron micrographs except that they were much more magnified and focused on sub-cellular structures as opposed to tissue specific structures. And for the unfocused slides, there was a question that is pertinent to the slide, and we had to search around the slide and use different magnifications to find clues that would let us answer the question. I must say that I was most worried about the histology practical because I didn’t know what to expect, but it turned out that the practical was my favorite exam. I think I studied most for the practical, so by the time of the exam I was very comfortable and actually enjoyed the experience.

So this week, we have a big test that culminates our integrated set of lectures on abnormal amniocentesis. The exam will take two days. Wednesday we have the biochemistry and genetics portion of the exam. Then Friday morning will be the written portion of the microanatomy/histology exam along with the gross anatomy embryology exam. Afterwards the lab practical for histology will be in the afternoon. And in case you haven’t already realized it, this exam is totally ruining my Labor Day weekend. It’s ok though, I could definitely use an extra day to study. In fact, yesterday I spent the entire day studying at school, 9am to 12:30 am! I didn’t even leave for dinner. The group I was studying with decided to just order a pizza and have it delivered to the school. Fortunately I’m not completely crazy yet, so I decided to sleep in today after yesterday’s studying marathon.

Once these exams are over I’ll have some time to reflect and share my experiences from this week. I’ve been pretty busy and haven’t had time to write, but once I have some more time I would really like to share some of my thoughts about some of the more interesting lectures leading up to this exam. But that can wait. For now, I’ve got a date with a microscope and a whole bunch of slides.

In today’s microanatomy lab we were supposed to look at slides from different types of connective tissue. But I couldn’t help but  get distracted and look at a slide from a cross-section of a human embryo! It’s amazing to think that at one point in time, I was an embryo no wider than the width of my finger!

Today we had an interesting lecture entitled, “Ethical Issues in Genetic Counseling.” It was probably our most interactive lecture yet, because it dealt with some pretty thought provoking issues concerning ethics in genetic counseling. In the lecture she taught us about the role of a genetic counselor. Basically, a physician can refer a patient to a genetic counselor for pre-natal screening in cases where a patient has elevated risks of birth defects. The risks include: family history of birth defects or genetic diseases, consanguinity (inbreeding), exposures to mutagens, recurrent pregnancy loss, or advanced maternal or paternal age during conception. Basically, one of the main roles of a genetic counselor is to help patients make informed decisions for their family, in a way that doesn’t influence the patient’s decision.

You probably have already gathered that this can be a very delicate issue. Whatever your stance is on abortion, I would like you to appreciate that there are very valid clinical reasons for pre-natal genetic screening. The lecturer tried to teach us about potential ethical issues that could arise from actual cases she has encountered. The names and scenarios were altered for obvious reasons.

At this point I would like to share a few cases I thought were interesting. During the lecture, she presented a case and asked for our opinion. After a little debate she told us how most clinicians typically handle these situations. So for now I will just present the case, tell you what is typically done, and allow you to share your comments and opinions if you would like to share. She presented a lot of interesting cases. Unfortunately we had 7 hours of lecture today so I have a lot to review, and I’m short on time. But I wanted to take a break and share a few examples of some of the cases. If enough people like this sort of entry I can write about the other cases later on.  So here goes.

Case 1: A 27-year-old woman who has already given birth to 4 healthy babies, is now pregnant again and wants a prenatal diagnosis. But she tells you that she would not continue the pregnancy if the child is a female.  What do you do?

Student responses:

-Perform the procedure, because it’s an elective procedure. It’s the patient’s choice and our responsibility to do so.

-Don’t perform the screening because there is no benefit to the patient, and it’s immoral.

Clinical Consensus:

- Typically, in such a case, the clinician wouldn’t perform the screening, and would refer the patient elsewhere.

-Most physicians wouldn’t do the screening in this case. Even though, it is an elective procedure, there is often a backlog of appointments and patients at significant clinical risk deserve priority.

Case 2: Now what if the woman from case 1 was 40 years old, and was referred for genetic counseling because of advanced maternal age?

Clinical consensus:

-Most physicians would perform the screening because there is a legitimate medical reason. Advanced age during conception increases the risk for birth defects.

Case 3:

-A woman comes in for a prenatal diagnosis

-Her husband’s mother and sister have Huntington’s disease

-(Huntington’s disease is a severe neurodegenerative disease in which symptoms appear beyond middle age.)

-However, her husband doesn’t want to know if he has the disease.

-It is an autosomal dominant disease, which means that if the child is affected, you will know that the father also has the disease.

What do you do?

Clinical consensus:

-Clinicians view the entire family as the patient.

-Refer back to my post about the white coat ceremony, and read the Hippocratic oath. (In it we swear to do no harm.)

-Informing the mother would indirectly inform the father. This would devastate the father. At this point there is a 50% chance the child would be affected, and wouldn’t be affected till later in life. So the risk to the father out-weighs the pros for the fetus.

-Note: she said she had a funny story where the mother brought in another man to pretend that he was the father in order to convince the clinician to do the screening.

Any ways I need to get back to studying. But I would love to hear what people would do in such a situation. And if you want I can add some more interesting examples later on. Thanks!

This Friday the student government organized an awesome welcome back party. It was a semi/formal party held at the Waterworks restaurant, which is a beautiful restaurant located on the edge of the Schuylkill River and across the street from the Philadelphia Museum of Art. They rented out the entire restaurant, and turned it into a cocktail party for all the med students to mingle and have a good time.

First off the hors d’oeuvres were amazing! There was a variety of food that

ranged from fancy items like ceviche, and seared tuna skewers, to finger foods like enchiladas with guacamole.  Either way, the food was delicious, and it was fun to taste some food that I hadn’t tried before but recognized from shows like Top Chef!

There were several areas to hang out in. First, the main dinning area was set up with tall cocktail tables, where people could gather and mingle.It was nice because I got to meet a lot of new people, and let loose with my class mates since we all finished our first exam the day before.  There was also a balcony, which overlooked the Schuykill River and had a beautiful view of the famous Boathouse Row. And of course, a med school

party wouldn’t be complete without a dance floor and an open bar. After everyone got their fill off of food and drinks, the fun really began when everyone started flooding the dance floor. Whether they were letting loose from the previous week’s exams, or taking a break from clinical rotations, by the end of the night everybody was having a lot of fun! The party started at 8 and ended at midnight. Like usual there were several options for after parties. I joined most of the first years at a bar called Public House, which was a short walk away from the event. I ended up staying till about 2 am and shared a cab with some classmates to get home. All in all, it was an amazing night.

In a way, this was like the last hoorah before school really gets difficult. This was our last major social event of the summer, and it was a great way to celebrate the first exam, and celebrate as a group after we’ve all become relatively adjusted to the school.

The best thing about the night is that I feel a lot closer to my classmates. I’m sure there will be many more fun times ahead, but for now I can put the celebrations behind me and embrace the hard work that lies ahead with a few good memories under my belt!