My First Blood Draw

The homeless shelter's free clinic was slow that night. The doctors suggested that we practice doing blood draws on each other and I went inside the trailer to observe. A girl was doing inserting the needle into a docs arm.

"Look away! You might feel a slight pinch!" she said, as if she were talking to a skittish patient instead of a hardened FP.

"Don't let go of the needle!" the doc said, commenting on her technique. "Hold it still so it won't slip out.

"Ok," she replied. Like a true ditz, she promptly let go of the needle to insert a vacutainer into the syringe-cover-looking thing.

"Uhm... you let go."

I laughed, a giddy nervousness spreading through my body. We're all inexperienced at these sorts of things. Even the third-year medical students aren't experts at blood draws; in the hospital, there is usually a nurse or a phlebotomist on hand to perform these routine (and for many, terrifying) procedures.

I had passed up the opportunity to attempt blood draws in the past. My preceptor at a small community clinic gave me the following advice about jumping in and attempting new procedures. "You will be an intern one day. For them, it is often see one, do one, teach one." Still, I chickened out on the big procedures. A small girl enthusiastically asked for a blood pressure reading one time. I attempted to read her BP and made her wince in pain as I pumped the cuff. "Whoops. Too much. I don't know what I'm doing..." I said lamely.

I quelled my nervous energy as the girl finished up, attempting to be professional despite the minor mistakes she made along the way. "Apply pressure on this gauze for two minutes and you should be fine!"

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A family medicine resident came in and surveyed the crowd. "I'm donating my left arm to whoever whats to try the next blood draw!" Suddenly, computer screens, pill bottles, and posters on the wall became the subjects of great scrunity. The only one who held her gaze was me. The other students shuffled back a few steps.

The resident seemed surprised by the response. "Doesn't anyone else want to practice?"

I steeled my resolve. I'm a MED student now, danggit! I gotta be willing to just jump into things and give them a go. "I'll try! This is only my second day of medical school though, so you'll have to talk me through it."

The resident smiled at me and said "Sure. Let me get all of the supplies set up for you." We retrieved some gloves, a small vacutainer, a needle-tube-needle, a rubber tourniquet, a few alcohol swabs, some gauze, tape and that barrel-syringe-cover-looking thing. Sorry, my terminology is not up to par. We spent a few minutes talking over the procedure and setting everything up so it was accessible and ready before I did anything with the sharps.

I learned a few tips that I would not have picked up just from observation.

Following the set-up, the rubber tourniquet is tied around the upper arm with a tucked loop. A simple pull on one end undoes the knot after the blood draw is complete. A tourniquet should be applied for no more than three minutes -- after that, the arm will begin to get the "pins and needles" sensation.

The subject pumps their hand a few times to raise the vein up. Tap along the vein to get a feel of where it is. Clean it with an alcohol swab, with a spiraling circle motion outwards from the point of entry. Hyper-extend the patient's elbow to raise the vein and firmly place your thumb on their lower arm on the vein. This will prevent the vein from rolling away from the needle.

Insert the needle bevel up (the hole angled towards you) along the vein at ~30 degree angle -- "scoop" a bit when you hit the vein so you don't puncture through the opposite wall. A flash of blood will reward you for your efforts!

Move your thumb off the vein onto the needle to secure it safely in the vein. Don't let it shift or slip. Bruising, pain or bleeding can result!

Take your other hand and insert whatever color vacutainers you need for the procedure into the barrel of the syringe-thingie. Blood should flow in by the vacuum. Don't let it get too full. Remove the vacutainer and replace with the next. Before you remove the last container, loosen the tourniquet. Remove the vacutainer before removing the needle. The FP doc told us of horror stories from his first blood draw with frothing, bubbling blood spraying out all over the place.

Fold a piece of gauze in half and place it gently on the site of injection. Don't push down hard. Pull out the needle gently and apply pressure. Have the subject fold their arm or apply pressure with their other hand while you get the band-aid/paper tape ready. Put the bandage on and you're done!

A few extra tips: used sharps go in the sharps container. Never place them down anywhere else. Communicate with the patient -- this will put them at ease and help you review what else you need to do.

Another first-year with whom I was tagging around with at the homeless shelter was emboldened by my success. For the rest of the night, the FP resident was walking around showing her bandaged arms to everyone she met.

"Two first-years drew my blood tonight," she bragged. "They both got it in on their first try for their first time!!"

It was a good feeling. :)

Here's a link on venipuncture for those of you who want to learn more.

Personal Mission Statement

The following is a mission statement that I composed as a guiding force behind my actions as I enter medical school. The template was provided by My Medical School's administration as a part of our orientation, but the values and the last two categories are my own.

We only had about 5 minutes to construct our mission statements, so the last one didn't go as well as I would have liked.


My personal mission is to be true to my commitment to myself and other as I fulfill the many valued and cherished roles that comprise who I am and who I want to be.

As a physician to be, I will strive to be compassionate, easygoing, and wise.

I realize that I am still learning how to be a physician, and as a lifelong student of the art and science of medicine I will demonstrate enthusiasm, curiosity and tenacity.

My family is very important to me. As a part of my family, I will always work towards being loving, attentive, and accepting.

My friends are special to me. I hope that I in turn can be an amusing, entertaining and engaging friend to them.

I am a proud member of My Medical School's Class of 2010. I hope to always prove to be a classmate that is diligent, dedicated, and sharing.

As a mentor, I will do my best to be inspiring, down-to-earth, and a good storyteller.

And for you, readers of my blog, I will always try to be perceptive, systematic and creative! :)

HepB Vaccine

"So, does anyone know anything special about the HepB vaccine? Anybody?"
We were all standing in a circle outside the shelter, about to open the free clinic and a medical school faculty member was quizzing us about the shots that would be given on Friday. I wracked my brain to try and come up with some ideas. Hepatitis B is a sexually transmitted disease prevalent in Asia and the Pacific, where vaccinations are uncommon. A lot of times, immigrants from these regions unintentionally transmit this disease to their American children at birth, raising their risk for cirrhosis and cancer.

"Yes, that's right! The HepB vaccine was the first of its kind to prevent cancer!" One of the MS-3s had nailed it on the nose.

A cancer vaccine? Hey, that sounds sort of familiar... weren't some Christian groups making a big hullabaloo about another STD vaccine that prevents cancer a while back? Cervical cancer caused by the human papillomavirus (HPV)?

"There is something about the HepB vaccine that has stirred up controversy. Does anyone know?"
I bolstered my courage to try and chime in with what I knew about the cervical cancer vaccine and how "Family Interest" groups were afraid that it would increase pre-marital sex in teenagers because they would go wild, knowing that their risks of cervical cancer would be significantly decreased! Alas, that was the wrong answer.

"There was concern that the mercury contained in these vaccines were linked with an increase in autism. Since then, thimerosal has been removed from all vaccine for children. But you should know that there has been no scientific data to back up the mercury-autism link."
Gah. I should have known this one, as an avid reader of Respectful Insolence. He is on a crusade to rid the world of this misinformation.

"Our governor recently vetoed a bill that would ban all vaccines with thimerosal in them."
Of course. Gov. Lingle was worried that Hawaii would be vulnerable to the avian bird flu if we put these sorts of limitations on a safe product. She was bold enough to state that "this bill is objectionable because it restricts the use of FDA-approved vaccines for no scientifically sound reason." I am glad that she can see this... which makes me wonder. What made our state government decide to write up this bill of nonsense in the first place?

What keeps me awake at night

Tomorrow is going to be my first day as a medical student. I am excited that I get to meet new people, in the clinic and in school. I am happy about learning medicine. I am disappointed that my life as I know it is drawing to a swift close. I am afraid that my biggest fear will be realized.

Am I afraid that I will look like an idiot in front of my classmates, preceptors and patients? Nope, I've already come to terms with my lack of intelligence. I'm ready to counter it with an overabundance of enthusiasm and curiosity.

Am I afraid of taking tests and studying hard? Nope, I already spend my free time studying medicine (albeit in the casual channels of science and medical blogs) and I'm ready for my swift kick in the arse after relaxing for a year.

Am I afraid of being disillusioned? I might be a little on the idealistic side, but I still have a good dose of realism/cynicism to save me from this sort of emotional burnout.

So what is it that keeps me up at nights worrying? Well, it is precisely that. Not the worrying part, the staying up at nights part! I love sleep. I have this notion that sleep is vital to my health and sanity. I have also theorized that I study better when I read a little bit and rest my eyes soon afterwards, coming up with mnemonics and cool visuals in my head. I like my theta rhythms... they help me learn and maintain memories for long-term potentiation. I am worried that I will spend too much time memorizing things and not enough time understanding them. I am worried that lack of sleep will turn me into a smelly Oscar the Grouch. I am afraid that my 8-10 hours of leisurely delta waves will be lost and I will be forced to rely on coffee/tea/Red Bull for their caffeinated boosts of energy.

I don't like the idea of relying on a stimulant to maintain my energy. If I'm tired, I'd like to go to sleep. I suspect I will be in for some harsh awakenings in the near future.


Here's some links on the subject of sleep and Red Bull!

Pop Science: the Chemistry Behind Red Bull's "Wings"
Retrospectacle takes a look at a can of Red Bull and discovers an ingredient that might provide energy aside from caffeine and sugar.

Everything you wanted to know about sleep (but were too afraid to ask)
The link between morning larks, evening owls, puberty and sex are all put together in this amusing entry by A Blog around the Clock.

Mind of Machinia

Matthew Nagle is a quadriplegic. Five years ago, he was a healthy twenty-year old who was assaulted with a knife. Now, he is unable to move his arms and his legs... yet he can turn on the TV, flick off the lights and check his email with a few silent mental commands.

Nagle is not telepathic; his powers are the result of advanced scientific research into computer-brain interfaces (CBIs.) CBIs have come a long way in the past decade as the development of our technology and our knowledge of neurology have both increased significantly. A special computer chip was implanted in the motor cortex of his brain, allowing him to move a cursor. John Donaghue, the developer of BrainGate, believes that this tech could someday move a mechanical limb or direct a wheelchair.

However, DARPA's dreams of mechanical robots and tanks driven by the minds of super soldiers and Ironman Mech-Suits are not fully realized. The technology is not perfect. It is still bulky, experienced technicians are needed and unusual training of brain waves might require special customization of CBIs for each user. Nagle's unit malfunctioned after seven months and he had it replaced with another device to improve his breathing. He lost his ability to beat lab technicians at Tetris, but he did give the hope that this technology will one day help people with Parkinson's disease, Amyotrophic Lateral Sclerosis (Lou Gehrig's disease) or other disabling conditions.

Source:
LA Times: Quadriplegic Turns Thoughts Into Action
EMBO: When Mind Meets Machine
BBC: Brain Chip Reads Man's Thoughts

Fast Food Nation

(Sorry about the break; I went on vacation for the week with my partner. We had a great time, but I didn't have any access to the internet for the week! Agh!)

I just finished reading the book Fast Food Nation by Eric Schlosser and I found it very engaging. Schlosser weaves intricate stories that illustrate the roles that various people have had on the fast food industry. The way he links Ray Kroc, the McDonald's man, to Walt Disney almost runs off on tangents, but turn out to be wide arcs leading back to the main point. The rest of the book is not as entertaining as it trudges through the harsh realities of strained fast food employees, slaughterhouse workers, struggling ranchers, all to pursue the American Dream of the Big Buck.

This Fall, the book will be made into a movie about a fictional company called the Big One (satirizing McDonalds, of course.) I'm not sure that it needs to be turned into a story, since the book does a good job as a documentary... but I suspect it has something to do with the success of the movie Thank You for Smoking.

Here, you can compare the book to the movie. Well, just the introduction of the book and the trailer to the movie. For more, you'll have to go to the library/bookstore or wait a few months in a theater near you.



Fast Food Nation: The Dark Side of the American Meal - Page 1


[add 7/23/06]
Here's some more clips related to Fast Food Nation that might be of some interest:
BBC hosted a debate between Schlosser and McDonalds!

Part 1


Part 2


Part 3

"The Master Cleanse"

Last night, I went out to eat with some of my friends after seeing the movie "Pirates of the Caribbean." My girlfriend mentioned that we had been "doing nothing but eating" since we had been at a beach barbecue right before the movie (which we did have a lot of food at, incidentally.) The topic shifted over to "diets" and it went wayside of scary crazy.

"I just finished with my seventh day of the lemonade diet!" One girl said happily to the group. My friend Ryan filled us in on the details. Apparently his parents swear by the health and happiness that results from drinking a quart of seawater every morning and consuming nothing but lemonade+maple syrup+cayenne pepper. Oh, laxative teas are tossed in every once and a while. It had cleared out the yellows in his mom's eyes, did wonders for removing toxins from their bodies and gave them cleaner energy.

The girl that tried the diet as well said that she was hungry at first, but then it went away and her mood improved, her mind cleared and she felt so much better. (My girlfriend got a load of attitude from her when we first met her before the movie started, so we did not really get to see any positive moods from her.)

Then, Ryan piped up with his own feelings about the diet. "It was horrible. I was bedridden for days, I didn't have any energy and I started puking up blood." His parents used seasalt instead of regular tablesalt for the diet and it probably tore up his stomach.

Puking blood is not the healthy part of any diet, the "master cleanse" included. The girl amended that her own doctor didn't recommend the diet -- he strongly advised to limit it to three days if she decided to do it.

"Soooo.... what was the name of this diet? Who was the health expert that recommends it?"
I asked, both concerned and curious.

"Oh, you can find it on the internet," they said almost dismissively. "Its called the lemonade diet."

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I did a little bit of poking around and I found links to pamphlets of books called the "Healing for the Age of Enlightenment (1993)" and "The Master Cleanser (1976)" by Stanley Burroughs. Amazon.com has some reviews by health nuts who rave about it and lawyer-types who rant about it. Apparently, Mr. Burroughs was charged with second degree murder for treating a person with leukemia without a medical license. The murder conviction was later overturned by the Supreme Court of California.

It is important to take the testimonials of people who try something like the lemonade diet with a grain of salt (pun intended.) There can be serious health complications and even worse results if the treatment oversteps its bounds as a "detoxification and cleansing diet" into its claims that it can magically heal all sorts of diseases. Leukemia is NOT something that can be healed with some lemonade and cayenne pepper; it takes serious knowledge to become a respectable medical practitioner.

Orac at Respectful Insolence says it best in a post about understanding alternative medicine "testimonials" for cancer treatments:

Never forget that alternative medicine testimonials exist largely for one purpose: To sell a product. Most of them are advertisements, nothing more. They are no more "unbiased" than pharmaceutical advertisements for their latest, greatest drug. In fact, they are worse, because at least the pharmaceutical companies have to be able to back up their claims with science and disclose potential adverse reactions in their ads. No such requirements exist for most alternative medical treatments, mainly because most of them claim to be supplements rather than medicines. The other problem with testimonials is that they don't rise even to the lowest level of medical evidence, the anecdotal report. Anecdotal reports in medicine require a careful documentation of symptoms, lab tests, diagnoses, exact courses of treatment, and a patient's response to treatment. Testimonials almost never present these elements in sufficient detail to judge whether the treatment actually did anything. There's just no way of telling truth from exaggeration or fiction.

If you ever read something on the internet that sounds too good to be true and they are trying to sell you something... be careful. Fact-check on reliable webpages. Read user comments and criticisms. Don't fall victim to hype and spin.

The avian flu creates a "cytokine storm" in teenagers

According to the San Francisco Chronicle, the H5N1 avian flu hits young people the hardest. This trend was also observed in the 1918 Spanish flu epidemic which killed over 50 million people. Teenagers are surprisingly susceptible to the disease compared to the elderly because of the peculiar way our immune systems fights off infection.

Evidence suggests that many young people in 1918 and quite a few in this outbreak are killed by a "cytokine storm" -- the body's own immune reaction, which floods the lungs with fluid. Young adults generally have strong immune systems.

In some ways, the strong immune systems of young people becomes our greatest enemy. Our immune systems work in such a delicate balance with our bodies... so it becomes too easy for some virulent invaders turn that to their own advantage.

This is the first time that I've heard the phrase "cytokine storm" used. A query in PubMed reveals that it has been used lightly in the past. Only 50 or so articles have used the phrase "cytokine storm", with the original published use taking place in 1993. Google Trends doesn't have much data to show for it, just a spike in search queries taking place in early 2006... but I anticipate that this will change quickly. In the process of political spin doctoring, all it takes to change peoples' perceptions is the coinage of a new term and turn it into something to be feared and reviled.

"Cytokine storm" sounds much more scarier than "bird flu." The human flu for most people is something that doesn't even warrant the effort to get a vaccine each year. The word "cytokine" is a mysterious thing in our bodies which will be translated as a "immune system messenger" that can easily send the wrong signals to our bodies.

Here's a cytokine that comes to my mind. Tumor Necrosis Factor alpha (TNF alpha) moderates our inflammatory response. TNF can kill cancer cells, hence the name. It can also kill healthy cells. TNF is involved in death when people go into shock. People who have high concentrations of TNF over time start wasting away and get cachexia.

See how spooky these things become? And thats always in our bodies, ready to be unleashed. When the H5N1 strain mutates from an "avian flu" to a "human flu that can kill millions," language like this will cultivate a more appropriate sense of fear in the public... as long as they don't get carried away in the hysteria. After all, gross hysteria and overreaction is just what this virus needs to kill you...

The Wiggles

I stare blankly at the screen of wiggles. Some of them wiggle at a regular rate while others look like an earthquake is ready to rumble through the hospital. Its scary to see how different they look... yet they both represent people that are very much alive.

"What does this mean?" I jab my finger at a sharp downward facing spike on the screen.

"Oh, that's a pacemaker." A nurse joins me in examining the screen, her eyes tuning in on the more important aspects.

"The spike is facing down because... it's located in the ventricular wall?" I think she nods, but I'm not sure. I think that the electrodes can pinpoint the location of the pacemaker, but I'm not sure. An alarm chimes and the nurse rushes off to check on her patient. My knowledge of cardiology is limited to reciting "PQRS wave" as I try to recall which part of the wiggle is the depolarization and repolarization of the atrium and ventricle.

All I can do is stare in amazement and shrug my shoulders as miracles are performed.

The heart monitor is like a crystal ball. Only those trained in divining its inner mysteries can understand what to look for and how to use that information. I can compare healthy wiggles to scary wiggly wiggles, but I don't know much about different leads, the amplitude and frequency of each part of the wave or how each heart condition manifests itself as electric current zapped wirelessly to the portal at the nurses' telemetry unit. I have a vague understanding of beta-receptors and ACE inhibitors, but IVs are still mysterious potions that course through the veins of the sick.

Knowledge is magical. It has the ability to transform weird wiggles into predictive power used to save lives. Someday I will be a magician.

Working Out

I went to the YMCA today and I had a long talk with one of my new friends there. He's been working at the Y for a while as a trainer for a few years now and he wants to open up his own business, focusing on the functional aspect of physical therapy and body building as opposed to the form aspect. He is a very smart guy and our talk made me realize that I don't know much about exercise. Not on a scientific level, at least... in my anatomy class, we spent a few months on the insertions and articulations of muscles and joints, but I haven't committed much of it to memory. My focus had been on studying the dysfunctioning body, but this doesn't make much sense unless I already have a strong understanding of the expertly functioning one.

An important component of exercising is doing it in a "proprioceptive-enriched environment." Proprioception is a part of our sense of touch. It adds context to our movements and allows us to recognize what position our body is in without looking at it. Our cerebellum coordinates our movements based on proprioceptive information we receive from muscle spindles and golgi tendon organs. Our brains learn to recruit muscles for certain actions, like running or dribbling a ball. Yet it is funny that we don't call professional athletes "smart!" They are in fact, cerebellar geniuses.

After about an hour of conversation, I started to exercise with a great awareness of what I was doing. A lot of machines in the YMCA activate specific muscles located on a chart posted on the machine... without incorporating stabilizing and synergystic muscles. While these machines make it easy for people like me to workout different muscles, they also have a big flaw, according to Mr. FunctionalFitness. Since they isolated muscles, they provided an inappropriate context for activity. It is better to work out with free weights, as long as you know what you're doing. I guess that's where the knowledge of a trainer comes in.

I did some workouts on the Freemotion machines. I haven't been to the gym in a while, so I think I'll be stiff in a couple of days, but I enjoyed it a lot too. I think a lot of things have worked out just fine.