A derepressing (not depressing) December

aka How I Got My Brain Stuck in the Alphabet Soup Jar

...and valiantly strove to fish it back out before 12:30pm Monday desperately hoping something had stuck.

Well, except the torture is over, so I'm not actually hysterical and can look back on this weekend with a healthy dose of amusement and sarcasm. In that vein, I invite you to enjoy a photo-essay.

I spent my weekend drowning in a sickly colored stew of enzymes and mechanisms involved in DNA, RNA, and protein replication, repair, processing, etc., with a base of genetics and modes of inheritance, flavored with diseases and molecular bio techniques, with some drugs to taste. My white board at some point said at least part of it best:

 (Ignore the cute doodles, courtesy my friend TQ; if only they were that accurate).

Despite having yet to crack the spines of any of my borrowed CMB textbooks, I felt kind of like Oasis and Ender, crushed under the weight of all that knowledge and despair:

 Raja, on the other hand, looked positively gleeful and extraordinarily pudgy conquering my mountain of textbooks:

I would almost wish to share his sentiments, except it would probably involve an immensely high volume of sugar intake to reach his girth, which is his secret source of power.

Sunday night found me studying the drug list. And consequently musing on all sorts of toxic scenarios therein. In short, I was going a little crazy:

(For the uninitiated, α-amanitin is arguably the most deadly amatoxin, in this case found in Amanita phalloides, or the death cap mushroom. It inhibits RNA polymerase II, causing the cells in your liver to burst, leading to death within a little over a week.)

Luckily, I made it to and through Monday, arguably in one piece, and hung out with a lot of pretty cool people Monday night to glory in our post-exam-ness. And as soon as I got back:

Boy was I tired.

Sworn in

Yesterday, I received my stethoscope in the mail. Today marks the two-week point since our White Coat Ceremony (shout-out to Dr. Lovering!). And this got me thinking.

One of my absolute favorite ICM sessions to date was the one a week before our ceremony, when we read through and discussed the various medical oaths that have come down through the centuries. Our profession is infused with a rich, inspiring history that brings with it the heavy weight of responsibility -- that day, we got a chance to touch on a small fraction of it.

I marked up my copies of the passages, but I just wanted to put down my thoughts on the parts that resonated the most. So, chronological order.

Hippocrates' Oath

Hippocrates, in the late 5th century B.C., set down many of the most basic tenets of medicine that we now take for granted. He swore his responsibility holding the Greek gods as witnesses. He stressed the familial/brotherhood aspect of medicine, and the importance of passing knowledge down to the next generation of disciples. His oath implied a separation between the art of medicine and the art of surgery. The oath introduced the concept of patient confidentiality. But most interestingly, in my opinion, was his very last sentence:

"If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

He didn't settle for, oh, if I do right, I'll do okay in life, but also stressed, should I do wrong, I should suffer the consequences of the violation of my responsibility. I think that idea, while not completely lost in the revisions and versions that came later, wasn't stressed quite as much as it was here, in Hippocrates' writing.

Oath of Maimonides

Maimonides, a Jewish physician and philosopher, also invoked his faith in his oath, written in the 12th century. He brought in another crucially important idea in practicing medicine: "May I never see in the patient anything but a fellow creature in pain." I can't speak from extensive personal experience, but from what I've heard and what little I have seen, this idea sometimes is forgotten in our over-eagerness to 'fix what's wrong' with our patient, and is often difficult to face. Another stigmatized idea Maimonides made mention of is admitting that yes, even doctors make mistakes. We can't afford to freeze up in face of them, but must learn, internalize, and carry forward.

Nightingale Pledge

A pledge first taken by nurses in 1893, named after Florence Nightingale, it made mention of something I don't think was quite as explicitly mentioned in any of the other oaths. Hippocrates did make mention of not administering deadly drugs to one's patients. This pledge, however, stressed neither taking nor giving any harmful drugs, acknowledging a medical practitioner's responsibility to both self and patient. It was strange to see that the pledge didn't make explicit mention of the 'art of nursing,' so to speak, the warmth that is often associated with it.

Declaration of Geneva

The Declaration of Geneva was first written and adopted by the World Medical Association in 1948. I suppose because it was an obviously international document, it more explicitly acknowledged issues of discrimination across many lines -- religion, race, nationality, political affiliation, social status, none should come between the doctor and his/her patient. This was also the second of our selection of oaths that included anti-abortion sentiments, after Hippocrates', which I suppose given the timeframes makes sense. 

Oath of Louis Lasagna

This one was by far my favorite of the oaths. Louis Lasagna put out a revision of the Hippocratic Oath in 1964, and injected a bit of quiet humor and poetry into his comprehensive breakdown. He acknowledged ongoing research in medicine and stressed avoiding the "twin traps of overtreatment and therapeutic nihilism." Lasagna wrote of the art and science of medicine, of speaking to patients regarding matters of life and death, taking care not to play God with a patient's life, remembering that you are treating a sick human being, that prevention is preferable to curing, and that we now are joining the ranks of a society that carries many an obligation. But most important, I think, is his hope to never lose the "joy of healing."

Student Oath

The student oath we read at our White Coat Ceremony was an amalgamation of many of these oaths, and incorporated almost all of the elements I most admired in the other oaths we read through. Wearing my shiny new white coat, I stood holding a sheet of paper full of words that grew heavier in the air as I breathed life into them anew, along with the rest of my class. As I reached the end of the oath, I felt the weight of those words settle from the air onto my shoulders, woven into the seams as tightly as they were into my psyche.

And it feels simultaneously humbling and thrilling.

Hanging with Yorick

Laurel and I spent some quality time in the pods today getting inside my skull. And I mean that literally, not figuratively.

If my blog were an anatomy atlas, I would draw in a bunch of arrows and walk you through the million foramina, fossae, and fissures therein. Thankfully, for the sake of both your sanity and mine, it isn't. Quirky person that I am, though, I will walk you through our time of hardcore studying.

He started out by sampling my caramel macchiato - I'm sure (I hope) coffee-making techniques have advanced for the better since his heyday.

Sadly, between the two of us, we polished it off pretty quick.

It potentially wasn't our brightest idea to caffeinate him, though. Pretty soon, he dived auditory meatus-first into 21st century technology, commandeering Laurel's iPod and rocking out to Outkast...

...after which he proceeded to chat up a storm of bone dust, and showed me a pencil tattoo under his eye socket that read "infraorbital fossa."

At some point, we gave up on the pretense of studying and spend many precious moments staring creepily at Laurel, much to her chagrin. Or amusement. I'm still not sure which.

We were having such a swell time, we didn't even realize it was time for solemn farewells.

On the bright side, we had a jaw-droppingly amazing time. Being crazy creepers.

(Shout-outs to Laurel, Dr. Pumplin, and Shakespeare)

Anatomy of Stuffing

I got back home last night around 11:45pm after an afternoon/evening of studying that started around 2:30pm and existed to highly variable degrees of productivity (often at the zeroth one - and that should totally be an ordinal!). First order of business, use my $5 Amazon mp3 credit, expiring in 15 minutes. And I now have a brand new album to check out! (Thanks for the help, DTD =))

Maybe it was the late hour, maybe I was finally cracking, but as I aimlessly spun around in my chair, my eyes alighted on my stuffed animals and I found myself idly wondering what their abdominal anatomy looked like. Say what?? My anatomy vision didn't get me too far, though -- all that stuffing got in the way, especially with Raja. And Sly was just too small for me to imagine much of anything. I was trying to superimpose a liver, which would dominate his entire front and then some. Oops. Just for reference, pictures:

Sly's the impish/sleepy raccoon in the middle

And Raja is the ginormous tiger Erik is cuddling up to

Of course, the logical progression from trying to visualize Raja's intestinal structure was to Google stuffed animal anatomy! Of course. It took some digging (and I somehow managed to restrain myself for a whole 24 HOURS before more fully indulging my craziness), but I found something super-cool! This answers almost all of my unresolved, burning questions about the innards of my stuffed raccoon, though I think there may be no hope for Raja:

Okay, so he's made of gummy stuff, whatever that's made of, and not teddy bear stuffing, but close enough. And he's a bear, not a raccoon, but it works, somehow. And, talk about AWESOME. The digital artistry, the level of detail, just...wow. I am blown away.

And the artist, Jason Freeny, happened to have something that tied in semi-perfectly with what I've spent the last couple of hours tackling: the female reproductive system.

Okay, so this image jumps ahead a few months, but close enough. Umbilical cord! Hemostats! Fertilization! HUGE BRAIN! Oh, wait, that's exam 3. Let's not get ahead of ourselves here.

And this last one is especially for Kevin:

I shouldn't be allowed near my blog after, say, 8pm, because my mental processes start breaking down. Clearly.

Bunnies and Inspiration

This whole blogging thing is more difficult than I gave it credit for, in terms of both frequency and content. How can I be expected to be consistently witty? I'm already using all my spare mental powers (of which there aren't many to begin with) to remember how best to permanently maim people --err, I mean, keep them ambulatory and healthy!

Speaking of witty, let's start with a story, because that's obviously a logical segue.

In an effort to keep up with my daily phone calls to my mom, I call her at 7:30 every morning on my way to lecture. After the morning pleasantries, the conversation always starts with her asking, "So, what's new?" Now, back when med school started (I say with a heavy sigh, as this was all of 7 weeks ago), I was all excited to give her the full run-down on fun facts from lecture the previous day or the latest body muscles/organs we had dissected out. To her credit, she wasn't at all grossed out, not even when I hesitantly told her about dissecting a breast.

All of seven weeks later, I'm already exhausted and grasping at straws for conversations that feel like they're coming earlier and earlier in the morning. Granted, fall's onset and the whole dark-at-7-am thing isn't helping. I'm a pseudo-morning person (by which I mean I'm not NOT a morning person, double negative intended), but all I can muster is, "Eh, studying -- nothing exciting." To which my mom pretty justly replies "What do you mean, nothing exciting?? You learn something new every day about your body, that should be very exciting! And then you get to dissect it out."

She's right, of course, as mothers are wont to be (darn them, except not really -- it's part of what we love about them, their extraordinary cooking skills being the other part). (Kidding!). But, back to the point. She's right. Every day IS exciting, even if I'm too tired in the mornings to fully appreciate this. And maybe this is just me being desperate to find the silver lining during our pre-exam week when we are all frantically studying our asses off and hoping we'll pass next Monday, but that doesn't make it any less true.

So we have 5238 bazillion arteries and nerves to memorize -- but just consider what an amazing work of art that makes our bodies. So sometimes our cadavers don't quite help us out as much as we'd hope/like -- there are a dozen other great dissections to check out to make up for it, and really, they're doing the best they can. So Merchanthaler's histo reviews confuse the bejeezus out of us -- ok, even I can't find the silver lining in this, except as Zeke keeps pointing out, he'd probably be hilarious to go out drinking with.

Heck, a handful of us managed to have fun this Saturday, courtesy of inter-pod communication! This sounds highly sophisticated and technical, but really, it was me, Zeke, and Laurel doodling back and forth on the glass separating walls with Prajna, Hannah, and Jared. About the reproductive system (mad props to Prajna for her off-the-charts doodling skills). And bunnies. And Zeke. Thumper! Followed by Pickles!

Point being: Don't let the stress and intensity get to you (she says hypocritically). Treat this time like the stepping stone it is, and kick back while you're at it (though not so far back that you fall out of your chair, *cough* Kevin *cough*). Rock on! \m/

Origins and Orientation

Until I've caught up on the first 1.5 weeks of orientation and 4.5 weeks of medical school, this will still seem too disorganized to me. Thankfully, probably no one other than me will care. So, as the saying goes: Let's take it from the top!

ORIENTATION (8/12/10 - 8/20/10)

The very first lecture I had in med school has easily been the most inspiring one so far: "What does it mean to be a physician/healer?" given by Dr. Richard Colgan. He spoke to us about the history of medicine, the art of healing, and a slew of thoughts for me to come back to for the rest of my career. It sounds cheesy and exaggerated, but it isn't at all.

We learned about many medical greats, most of whom I admit I hadn't heard of before, but I haven't been interested in history until now, so I suppose that comes as no surprise.

Hippocrates: First do no harm

Sir William Ostler: Equanimity and imperturbability

Francis Well Peabody: 'For the secret of the care of a patient is in caring for the patient'

William Carlos Williams: One of the best trainings you can have as a writer is to be a physician - people will tell you the most intimate details of their lives that they may never have told anyone else before and won't tell anyone else again

Theodore Woodward: 'Don't be a slip doctor'

Dr. Kalia (sp?): 'When you're not sure what to do, remember: focus on the patient'

Dr. Colgan: 'What does it mean to be a healer? Smart. Philosopher. Loved and hated. Case worker. Patient's advocate. Respect and disdain. Accountable. Challenged.'

I only wrote up tidbits from a handful (the ones I managed to scribble down legible quotes for), but the talk, the history, was inspiring in its entirety. The rest of the talks were well and good, but nothing quite stood out the same way, with the same relevance and gravity.

A couple of days later, we were introduced to the wonders of the MASTRI center, which is the simulation lab on the UMB campus. The traditional saying in medicine, especially regarding surgery, goes: "See one, do one, teach one." As the MASTRI tech put it, "See one, simulate many, do one, simulate some more, and then maybe you can hopefully teach one." After watching a couple of fellow classmates take a shot at simulated gall bladder removal, all I can say is, I'm definitely hoping.

Next up, medical ethics. This is an area I've always been very interested in, but my undergraduate schedule conspired against me whenever I tried to take a class in it. It focused more on breadth than depth, but even the brief overviews gave plenty of food for thought.

Four approaches:

1. Utilitarian philosophy - end justifies the means
2. "Rules" - No matter what good you might do by breaking the rules, you must always follow the rules
3. Virtue ethics - do you act virtuously?

4. Case-based decision-making - can you do each case on an individual basis?

Four principles:

1. Beneficence - doing good
   Nonmalificence - or at least, do no harm
   Should this be put above all else?

2. Autonomy - patient has a right to drive their own info, make their decisions, etc.
3. Justice/equity - should be some rough justice with how patients are treated

4. Integrity - of us individually and of the system

Of course, the complications arise in how you apply these approaches and principles. What happens if they conflict? What if you and your superiors don't see eye to eye? Or you and the family? You and the patient? Where do you draw the line at determining whether a patient is of danger to him/herself? How much responsibility can you assume in the doctor-patient relationship? There are so many more questions, but I have no basis to evaluate them on right now, so this will definitely be revisited.

Also, Dr. Mallott is a fantastic speaker. Just for kicks: "One day, my kids asked me, 'What do you do?' This is when I was in the in-patient psych ward at the hospital. 'Mostly I deprive people of their civil rights.'" -Dr. Mallott

Sometime after, we had career counseling with Dr. Martinez, another fantastic speaker, super-cool guy, and his presentation was simultaneously informative, nerve-inducing, and reassuring. Don't ask me how he pulled all of those off together, but he did. He threw a bunch of career ideas and summer opportunities at us, then promptly forbade us from thinking on it until after the first exam. Mostly, he left us with: "Learn to be comfortable with being uncomfortable." Yessir!

There were a few other highlights, too. The fashion show was entertaining, though I was heartbroken to learn I could no longer take my exams in my wallowing sweatpants. Also, tragedy of all tragedies, I don't have a sewing machine. Dr. Dolan held a talk on study tips and academic counseling with Dr. Keller, which gave us some vague ideas on how to kick our first week off right.

I think that closes out orientation week. Somewhere in the midst of all that, on the 15th, I made my first foray into having a 'thought of the day' (which I subsequently abandoned for a week). Here it is again:

 It's finally starting to hit me, the weight of responsibility that promises to grow heavier with each passing day, every ounce of knowledge. The idea is too much to wrap my head around.

It occurs to me that it might come across as defeatist, which was entirely NOT the idea behind it. In fact, that very weight and enormity is incredibly galvanizing, almost uplifting, and I hope it remains to be so. 

Initials: JCT

It seems fitting somehow that the first person whose story I tell is my grandfather. And in a way it’s my own story, too – his started long before me, but mine started with him. This journey I’m now embarking on, this started with him, too.

Barepapa loved to spin a good tale, some true, most humorous. Growing up, I knew him as a singer, a jokester, a caretaker, but first and foremost, a friend. He was my first playmate, and we were thick as thieves. Being a grandparent means being the designated keeper of illicit secrets – Mister Rogers TV marathons, extra trips to the park, a third helping of ice cream.

My memories of him make up a good portion of my childhood. Our ritual of walking to school started in kindergarten, when school was actually right down the street. I had PM classes – he would get me ready, feed me chicken noodle soup, and off we went. When I came home, I would take a nap with my head in his lap, on my favorite baby pillow. He and I had a game, where I would try to sneak up on him from behind, treading softly on my tip-toes. His hearing was so sharp, he never missed a beat, always turned around and swung me up before I even got close.

He loved to take us all to the park, pushing us on the swings and vainly trying to keep his little terrors in line. I remember he always dressed sharp. Every day, he had on his dress pants, a nice button-up shirt, and a belt, with his favorite sweater vest over top, rain or shine.

Barepapa dedicated much of his life here to raising us and looking after Barimama. She passed away my first year of high school, and Barepapa took it the hardest. He suffered a string of health setbacks, and very slowly began losing his recent memories. He had begun down the path with Alzheimer’s, and it was a roller coaster from there – frustrating for him to ride, and heartbreaking for us to see. One of my saddest days was when I successfully snuck up on him, and he didn’t hear me, didn’t see me, didn’t turn around.

In his spare time, before his eyesight and motor control began to deteriorate, Barepapa had filled journal upon journal with his poetry, shairo shairee. Any time we got together for prayers, he sang his favorite bhajan, “Aye Mere Gurudev Karuna,” and as he lost his memory, that refrain increasingly echoed through our home, a lament and a prayer.

I started college close to when he began losing his memory. Every time I left for school after a weekend home, he would slip some pocket money into my hand, tell me to study hard and come back soon because the house was too quiet with me gone.  

Soon after, his memory took a steeper decline. He steadily lost his sense of self, his awareness of everyone else. I came home one weekend, sat down to tell him a story I’d heard; he sat there listening, and as I looked at him, I realized there wasn’t the faintest glimmer of recognition in his eyes. He didn’t remember who I was; that knowledge never came back, and I knew I’d lost him, thought it could never hurt more than it did then.

This past year he couldn’t take care of himself anymore. Barepapa, once such a proud, self-made, independent man, was suddenly dependent on everyone around him. The fact that he wasn’t aware of the autonomy he’d lost made it that much harder to watch, to help him.

And these past two weeks were a different kind of torture. He stopped eating two weeks ago, and I was at school, away from home, away from family, away from him, confused about how to deal with this on my own. I came home the weekend before my exam because Mama wasn’t sure he would make it to Monday afternoon when I got done, and I’m so glad I got a chance to see him, to talk to him, even if he couldn’t respond. My leaving didn’t make the house quiet; his leaving did.

When he passed away Thursday morning, I somehow felt I hadn’t just lost my grandfather, my oldest and dearest friend, but also lost my last connection to my grandmother. They both made me who I am, were my inspiration, my driving force my entire life, and I didn’t know how to handle the thought of losing both of them, what felt like a second time.

And then one of my closest friends in high school, whose grandfather passed away a year after Barimama, wrote me a beautiful e-mail. She said, “One of the only things that made me smile when my grandfather died was something you wrote me in a card that I’ve always kept. You asked me to imagine our grandparents sitting in heaven somewhere having tea together, happy and free of all their earthly burdens.” She re-gifted me a precious image, of Barepapa and Barimama meeting again, sitting on a bench somewhere, spending eternity together sipping chai and gossiping about the rest of us.

Throughout high school and college, he would write me little notes, and I always kept one with me in my wallet, reading it when I was thinking of him. The latest one was a quote he transcribed for me:

“Everything will straighten itself in time
Only we need patience, faith, self-surrender,
The Lord is great
HE knows best the purity of every thought, action, and motive.”
-Swami Chinmayananda

And he also wrote something it seems especially for us today:
“We should never be afraid of tears. They soften our hearts, wash our eyes, and clear our vision.”