March 19, 2008

Are Glow-Sticks toxic?!?

MSDS = Material Safety Data Sheets

I learned about MSDS during an on-job training at my first job in high school, the brutal, dangerous environment aka McDonalds. I got splattered with oil and I burned myself more often than not (not seriously, mind you) working at the grill. When I found myself a nicer summer job at the YMCA as a camp counselor, I jumped at the chance. How cool is that, to get paid to play with kids and have fun?

It turned out to be more work than I imagined. My relationship with the kids had to swing from the Fun Guy to the Enforcer on a dime. The trouble-kids always became the ones I was most fond of at the end of the program... perhaps it was just a consequence of spending so much one on one time with them. I remember one kid had a glow stick in his mouth (for some reason) and he freaked out because it broke and he swallowed some of it. "Oh don't worry... it's probably non-toxic. I'll take you to the supervisor and we can check that. For some reason, I was under the impression that the MSDS sheets at the YMCA would have facts about glow in the dark chemicals. My supervisor gave me this weird look when I brought him in and said "what... are... you... talking about?" She was only a few years older than me, but she had mastered the ability to talk down to someone that stood almost a foot above her (taking some poetic license here.)

Still, that incident stuck with me. What IS the effect of glow stick stuff on the GI tract?

Tonight, the answer is solved, thanks to ToxNet, a resource brought to my attention by the Health Sciences Library.
Most incidences of exposure to chemiluminescent products involve asymptomatic ingestion of fluid that leaks from glow sticks or ingestion of an intact glow stick. Symptoms occur after exposure to chemiluminescent fluid and consist of transient irritation at the site of exposure.

Figures... went along with my instincts. Perhaps I'm revealing my level of hidden neuroses, but my mind feels more at ease knowing the easy way to find the answer to these questions. All I had to do was go to ToxNet and type in "glow stick" into the search box.

More and more, knowing random trivia bits will come from knowing WHERE to look... not necessarily just Knowing. The internet is very two-faced though. For every bit of information out there, there's 10x more garbage (growing day by day) Everyone should begin acquiring their set of reliable fact-checker bookmarks (like to combat these sorts of things.

References: Hoffman, RJ. Pediatric and young adult exposure to chemiluminescent glow sticks. Arch Pediatr Adolesc Med. 2002, Sep; 156(9):901-4.

March 14, 2008

Sleep Hygiene: a self-critique

I recently prepared a presentation on sleep apnea and sleep hygiene. I tacked on the bit about sleep hygiene because it's a concept that's quite foreign to me and I wanted to learn more about it. Quite frankly, I suck. I routinely go to sleep around 3 or 4am and I take a nap in the afternoons to try to catch up on my sleep deficits. On days when I can't take a nap, my mind wanders, I yawn a lot, I feel on the edge of nodding off around 3 or 4pm.

Here's some of the basics about it:

  • Areas important to sleep hygiene:
  • Circadian rhythm
  • Aging
  • Stress
  • Common social or recreational drugs like nicotine, caffeine, and alcohol
  1. Adapt your habits
    o Set a bedtime and waking time (no sleeping in more than 2-3 hours on weekends)
    o Avoid napping (if you do, make it short and before 3 pm)
    o Avoid EtOH, caffeine, heavy/spicy/sugary foods 4-6 hours before bedtime
    o Exercise! (but not right before bed)

  2. Adapt your environment
    o Comfortable bed, comfortable temperature, dark room
    o Block distractions (NO TV, NO computer for at least an hour or more before, but radio is OK)
    o Only two S’s for bed
    o Proper positioning

  3. Prepare yourself nightly
    o Light snack (warm milk)
    o Relaxation techniques
    o No worries in bed!
    o Pre-sleep ritual

  4. Problems?
    o If you don’t fall asleep in 20 min, go do something else (like reading) until sleepy (~20 min later)
And here's my self-critique.

My waking time varies every day. Basically, I set it as late as possible so I can sleep in because it's just so hard for me to get up in the morning. I nap around 4-5pm whenever I can, which is usually 2 or 3 times a week. My naps are about 1-2 hours long, depending on what finally rouses me (usually hunger). On the plus side for me, I hardly ever snack late at night (but it's not really a problem for me to go to bed once I'm there. It's more an issue of studying when I feel most mentally alert... it's just unfortunate that it happens to be 10pm onward.

My environment for sleeping is pretty good. I actually sleep on a bed now, which different from the ~20 years of sleeping on a futon at home (the parents' place) One of my S's is lacking... I've pretty much replaced it with another S: studying.

My pre-sleep ritual usually involves brushing my teeth for close to half an hour while I browse blogs on the internet (or on especially good days, I decide to blog!) Perhaps an unwise decision, since the lights from the computer screen and the content of the blogs stimulate me and I decide "oooh, another 15 min wouldn't hurt..." and before I know it, it's 3am and I've got class at 830 tomorrow.

So my sleep hygiene is about as bad as it could be. If I want to start sleeping earlier and reset my circadian rhythm to a more decent hour, I've got to exercise more, stop my midnight blog browsing, and stop studying in bed. I should have a warm glass of soy milk, settle in with a book and read for about 15 minutes before turning in at midnight.

Ha! I wonder if that's even possible to manage, med school and beyond.


Reproductive Issues

Today was a day of reproductive problems.

I went to the Maternal/Fetal Medicine department at Queens and I shadowed a physician there for a few hours. She was a "problem-pregnancy specialist."

The first patient that we saw was a young woman with suspected preeclampsia. It's basically a condition of high blood pressure, protein loss in the urine and sometimes accompanied by edema. It can lead to further complications like seizures, preterm delivery and stillbirth, so it can be pretty serious. She had chloasma and linea nigra, darkened pigmentation of the cheeks and a dark line down from the belly button. It was the first time I'd ever seen (or heard) of it. It's also called the "mask of pregnancy."

I had a good time chatting with her and her husband about school and their physician and such during their non-stress test (fetal heart rate monitoring) that I missed the beginning of the Dr. B's next patient encounter.

It was with a young diabetic woman who recently found out that she was pregnant. Unfortunately, she is a "RFN", meaning that she has retinopathy (can't see), ne'f'ropathy (kidney problems) and neuropathy (sensation loss in her lower legs.) These are long term complications of poorly managed diabetes and from the looks of it, she had a lot of support problems in her family that prevented her from getting quality care. It was really sad, because it meant that she had to make a difficult choice -- continue the pregnancy and risk early preeclampsia, possible miscarriage and progression of her blindness and kidney failure that would put her on dialysis... or terminate the fetus.

I... I don't know what to say about this. There were some other emotional issues that complicated her decision-making process that really surprised Dr. B. and I. I wish that Dr. B. followed up on it, because it was quite striking. Perhaps at a later visit she will. It's a tough position to put anyone in, deciding which life will suffer to ensure the welfare of the other.

Perhaps it could be a blessing for her if she decides to continue... I said hopefully. Dr. B. expressed her doubts and I can see why. She has difficulty maintaining a stable life for herself; adding a child would just be an additional stressor. The child will likely have a lot of complications due to vascular insufficiency in utero... diabetes is one of those silent systemic diseases that wreaks havoc on all parts of your body but doesn't let you know what it's doing until it's too late.

I left that obstetrics session with a lot of things to think about. How will I handle these issues with my own patients? What level of autonomy vs paternalism do they want? After all, it takes an expert's opinion in order to figure out what to do... and then the choice is left up to an overwhelmed patient. On the other hand, being harsh or judgmental affects the relationship with the patient who relies on the doctor to be their advocate... it would undermine everything to pull in biases and overrule what is in the patient's best interests.

I guess it all comes down to that. Interests. Values. Discovering what matters most to the people you see in the clinic and seeing how that affects their decisions. Helping them to understand the significance of the issues at hand and the role that they play.


Later on tonight, I went to the homeless shelter near school to help out at our free clinic.

One of the fourth year students gave a short talk entitled "Reproductive Issues in the Homeless." He shared some statistics with us, basically saying that physicians often avoid the issue of sexual matters with homeless and that limits their contraceptive use. Ironically, being monogamous and not engaging in sex trade is actually associated with lower contraceptive use since "commercial sex workers" are the types who seek out these methods of protection.

Some of my classmates, so inspired, decided to take a bag of condoms and distribute them to residents of the shelter. Later on, he told me that a lot of the women there would initially refuse to take any condoms, but when pressed, they would glance around, see if anyone is looking.... and then they'd take the entire cup of condoms being offered.

Truly there is more we can do to help these women in the area of reproductive health than just offering them a dozen condoms on a particular night. A lot of them have health insurance and just educating them about some of the options (IUDs, rod implants, Depo-Provera) can go a long way.

All in all, it's been quite a day for me.

March 10, 2008

Munchausen by proxy

I first learned about Munchausen syndrome by proxy through the movie Sixth Sense, where young Cole conquers his fears and learns why he is being haunted. A young girl shows him a videotape revealing that her mother intentionally poisoned her to keep her sick! WTF?!? People really do that?!? I felt ill. It was totally outside of my realm of comprehension. In our last Unit on Neurology and the Musculoskeletal system, one tutorial group had a running gag when they hypothesized about the diagnoses for the cases: ascending paralysis? Munchausens. bouts of mania and depression? Munchausens. kids having trouble walking? Munchausens by proxy. headache? I think you get the point.

Browsing through my blog reader today, I came across this:
A Redlands mother of four was accused of Munchausen syndrome by proxy, fabricating or inducing illnesses in her own children
-LA Times, via the Lone Coyote @ Medical Student Musings

It certainly must be frustrating to deal with hypochondriacs... even more so with hypervigilant parents! Every little cough or sniffle becomes a sign of some impending disaster to the point where the doctors become desensitized to the Truth. Just because someone is seeking attention for a medical illness that they read about on the internet doesn't mean that they are Attention-Seeking and worthy of only a cursory exam and subsequent dismissal.

Perhaps this is just my naivete and inexperience speaking, but the patients with the irritatingly vague and persistent complaints may just BE the ones who deserve the most attention and cognition. Maybe, just maybe, they have a genetic condition like Ehlers-Danlos Plus (though I couldn't find it definitively on OMIM) with a chiari malformations that could explain the seizures, centralized sleep apnea and joint dislocations.

March 06, 2008

No, I can't do this all on my own...

I'm no.... I'm no Superman. doo doooo do dooo dooooo....

Scrubs is one of my favorite TV shows that I don't watch. It jumped around a lot and I always thought that JD was too silly, but in many ways, he's my role model. He takes sad and bad situations and turns them into funny and amusing situations and really, that's the whole point of Scrubs to me. It's a sitcom about serious topics like life and death.

Still, I don't like to watch it. Why? It's always served as a warning flag.

Last year, I discovered a website that hosted all of the previous episodes and started watching them from Season 1 onward. I'd typically watch 5-6 episodes a night in lieu of studying and it almost felt like an addiction. I felt down about the whole med school thing and for some irrational reason, I felt like no one at school really liked me. It was easier to just watch another episode than it was to crack the spine on one of my textbooks... it wasn't until I failed my Anatomy midterm that I snapped out of my funk and started studying again. Luckily, midterms just serve as a wake-up call and don't count for credit.

I fell into this pseudo-depression last week as I restarted Season 1 on DVD.

I saw it as a good opportunity to learn more about defense mechanisms. The show is chock-full of psychiatric issues! It was quite funny/dorky to watch My Heavy Meddle and think "Oooh! Dr. Cox is pissed off and he's using Displacement to vent his anger towards inanimate objects. Of course, J.D.'s main defense mechanism is humor (which is one of the mature mechanisms, but every time he flips into one of his extended fantasy, it seems whimsical and childish to me.) Almost all of the characters utilize altruism as well.

In My Old Man, Turk and Eliot's parents come to listen to a presentation and J.D.s dad decides to visit also... and they all regress back to childhood! :)

In my examination of the different characters, I realized that I was just intellectualizing the entire process to hide from my own anxiety and loneliness. That's always been my response to things and it's served me well -- it helps me understand things technically, but it comes at the cost of sacrificing my own emotions.

Dang. I can't handle these sorts of things on my own. Once again, the underlying wisdom of Scrubs saves the day, ironically and I stopped watching it to get back to the issues at hand.

March 04, 2008


Thirteen years ago, I met a group of people who crouched around a map with tiny miniatures scattered around it and rolled dice as they exclaimed what their imaginary characters were doing. I read a lot of fantasy novels and it SHOCKED me that you could sit down with a group of friends and play a role as a character for fun! We played Dungeons and Dragons during recess. I was a hobbit by the name of Shorty, who loved to play the flute and annoy people. Shorty was very good at being sneaky and he eventually got the ability to fly. It was a silly game, but it meant a lot to me as a seventh grader. I learned about philosophy through the game. I found a website hosted by a doctor! who called himself the Pathguy and in his spare time, he wrote blurbs about other planar dimensions filled with mythical creatures and treasure, as well as world-views and values.

Sadly, I found out that Gary Gygax passed away today. He was one of the creators of Dungeons and Dragons that inspired a generation of geeks to channel their creative energies and create entire worlds for storytelling and fun. So much of today's movie and video game industries have him to thank for providing the framework for gaming.
His wife, Gail Gygax said that he had a lot of health problems for several years, including an abdominal aneurysm. Despite his declining health, he hosted weekly games of Dungeons & Dragons as recently as January, she said. "It really meant a lot to him to hear from people from over the years about how he helped them become a doctor, a lawyer, a policeman, what he gave them," Gygax said. "He really enjoyed that."

I am one of those fine citizens that benefitted from the cooperative adventure game he created. I still play to this day. Through D&D, I learned about leadership, cooperation, tactics, problem-solving, resourcefulness, attention to detail, mastering obscure rules and most of all, empathy.

I love stories. One of the things I feel so lucky about as a student doctor is my opportunity to hear the stories of my patients! They give me with small snippets of their lives, bits and pieces that I scribble down onto their character sheets. Then I report to the attending physician and get my experience points in the form of teaching topics. My life may not have a Dungeon Master guiding me along on a quest to rescue a damsel in distress, but I do feel glad that I get the opportunity to play a hero sometimes :)

March 03, 2008

woot! new blog format up.

A friend told me that she lost the link to my blog a while back and that's why she stopped commenting. A few new people stumbled upon my blog somehow and one of them even offered to interview me!

Wow, it's nice to have that sort of attention. :)

After two months of puttering around with some minor changes, I decided to clean house and unveil my new blog. ta da! It probably looks the same as always. Perhaps the most important change I made was a mental one.

I reviewed some of the questions on Y.S.'s blog. It made me think about my motivations for blogging and what I had hoped to gain from all of this extra work. My biggest reason for blogging was for self-reflection. To think about the things I've done and form opinions about them. Somewhat ironically, I picked the name "Not My Second Opinion" as if I had some outrageous and strong opinions about subjects, like the folks at MDOD. I'm actually quite conservative (not in the political way) and I'd hate to be caught in the middle of a flame-war.

Let me tell you about my biggest fear with this blog though. I was afraid that someday I would get hauled into the Office where an Administrator would pull out my blog and list the violations I made to their Honor code and the privacy violations I made to HIPAA. The infractions would be minor, like mentioning a neat fact I learned from a case on that particular day, except it gives away the diagnosis of the case. Since the first two years of JABSOM is based on these cases, it constitutes cheating to provide this information to students. Arrgghhh!

There's been a lot of times where I wanted to share some things, but decided against it, erring on the side of caution. I've been burned before.

Still, I'd like to throw back the curtains of anonymity. Hello World! My name is Clinton. I'm a second year med student currently going to JABSOM, Hawaii's medical school. I love it. It's a strong cooperative place and my classmates are the best friends a guy could have. I'd like to start sharing my experiences with you as I move into my Board studies and prepare for my third year of school... that exciting, sleepless time filled with great stories and interesting patients.

I'd like to begin blogging fearlessly and passionately once again. After all, it's personality, not really content that drives Blogs. Otherwise they'd just be called websites with regular updates.

March 02, 2008

I heart the Google

I'm not exactly an early-adopter when it comes to new technology. I don't like to spend a lot of money on the latest souped up laptop mobile phone, PDA or digital camera. I prefer something that is cheap and popular because it's familiar.

However, there's one situation where I'm all for the early-adoption.

I remember the first day I was introduced to Google. It was back in high school, during my sophomore or junior year. Mind you, this was a time when search engines were horrible things to use; there was some clunky programming language you had to learn in order to pull up items from the internet to make it remotely useful. This was a time of Gopher and AltaVista and Yahoo. I was at my friend J's house (where we'd occasionally convene to have "LAN parties" and hook our computers together to play a game) and he said "hey, there's these people from stanford that are trying this new idea out for search." I liked the layout. It was clean and simple. It bugged me that they misspelled the word googol though... but it was a dream to use.

Since then, I've been keeping track of their progress into internet apps. I use Gmail and Google Reader as my main processing applications. I tried to convince my friends to use Google Docs with only some success. I heart the Google.

Google is free.
Google is open.
Google is creative.
Google is friendly! Recently, I emailed Google Scholar the suggestion that they include PubMed IDs into their searches. Less than a day later, I got an email from one of the developers, thanking me for the idea! Cool beans.
Google's motto is "do no evil"... which pleases me immensely that a company believes in something like the Hippocratic Oath.

Google's latest endeavor is Google Health., announced on the Official Google blog a few days ago. My local drugstore (Longs) is participating with Google as they prepare to debut the Personal Health Record later this year.

I'm very excited about this project.
As people collect more and more of their lives (their e-information) online through photos, diaries and other such services, it makes sense to have something like their Health accessible as well. It's the ideal of Patient Autonomy -- a quick list of their medications, further resources for health topics they are interested in, a link to their family history, etc... all at their fingertips should the need arise. I can foresee a subset of very involved, very dedicated net-savvy people utilizing the PHR to great effect.

However, I've got a few questions.
  1. Who has access to what?
    * Will doctors be the only ones who can modify the patient's list of medications?
    * Security problems are of special concern in this area. I already dread the idea of someone finding my username and password because they could hijack my gmail, my subscriptions, my blog... basically my entire internet life. What would happen if a hacker got ahold of my health as well?
  2. To what degree will patients finesse their PHRs to sound good? I was surprised the first time I got ahold of my own medical records and found that 'patient denies smoking, drinking alcohol or using illicit drugs.' I'm not in denial! It's a language thing and the point remains.
    *Will patients lie about their diet, exercise and other lifestyle choices more or less with a PHR than with their own doctors?
  3. Will this affect the quality of health information find through "google"?
    *Free medical information is not equivalent to trained medical judgment. I have access to the same free info that everyone else does (yay!), but I'm learning more and more everyday what it takes to be a clinician. It requires journal articles and guidelines and understanding of basic science and mechanisms of action... which are all found more easily through closed channels than the open ones.
  4. Will people have better contact with and access to their doctors through the PHR?

Eric Schmidt, the CEO of Google Inc. provides a few answers.

He starts off with great story how Google saves a man's life (he was having a heart attack, typed his symptoms into a search engine and the first hit said: you're having a heart attack. dial 911.")

PHRs have been done before. Google Health aims to integrate closed-systems and help them talk to each other. Standardization is currently lacking in fields like cell phone menus and health management systems.

You own your own PHR data and determine who has access. Transferring to a new doc? Boom. Privileges granted with a simple shift in privacy settings. Trust is important to Google.

Cloud-computing, server-side storage of important information means that your information will be accessible via any computer rather than just one hospital or one clinic.

A health advisory counsel was formed to advise Google on the services needed. Issues like organization, reliability and security, the same concerns that I have are mentioned.

Companies like Longs, Walgreens, and Walmart, as well as places like UCSF and Cleveland Clinic cooperated with Google through a series of ongoing projects to try and integrate Google Health into their services.

Go to ~30:40 to hear more about "Diana", the Cleveland Clinic patient. Her conditions page has a list of things that she added herself, as well as those she added in from her doctors. A safety check alerts her to a prescription of amoxicillin since she's allergic to penicillin. Health reference pages provide basic context on health conditions, illustrations, news, web searches, google scholar links and discussion groups. Diana can opt to "connect" her PHR to third-party programs. A google gadget can provide her with medication reminders to her google homepage(hey, maybe a text msg would be a better idea!)

A few other notions are entertained and illustrate Google Health's potential for offering even more services. They like the idea of a mother writing a vaccination checklist for her kids, news alerts on a Cure for their condition (which brought laughter to my lips in delight)

Q&A follows, bringing up questions on the success and long-term implementation of something like Google Health, Doctors being informed by Google Health, Monetization of Medical information, Open-vs-Closed models, Google EMR for billing and insurance, etc.


Disclaimer! I know very well that I'm just promoting Google through viral advertising, but they've got some great ideas and I've always been a huge fan. I hope Google Health succeeds.... hey and maybe someday I could get hired as a consultant! hmmm?!? hehe.

March 01, 2008

Simulated Patient Experience

One of the most exciting things about the first two years for me here at JABSOM is our clinical skills lab.

Here, we get to perform our fledgling clinical skills on "simulated patients." Sometimes they are trained actors mimicking specific health complaints. Other times, they are computerized mannequins programmed to crash in certain ways. "Doctor, his vital signs are dropping rapidly. He is desatting below 60! What do you want to do?!"

I always find them to be terrifying. Not in a crippling sort of way, but a heart pumping, anxiety filled sort of way. These clinical skills exams are few and far between, scheduled around weekends or holidays so they don't interrupt our regular programming.

They started us off easy in the first year. We would interview a patient on some sort of psychosocial issue; it was rarely a difficult medical problem, just some common topics that come up like "giving bad news," "talking with a difficult adolescent," etc. Everything culminated in the performance of a full basic physical exam, from head to toe, excluding the breast, genital and rectal exam, in 15 minutes. Whoa! I would inevitably skip a few steps (usually forgetting to listen to the carotids for bruits or perform an axillary exam,) but overall, I'd be ok.

The second year has been a little more difficult.

We've had a few sessions with mannequins where we had to manage a comatose patient and a newborn baby. Those were really fun! I felt the adrenaline pumping through my veins and a sense of preparedness after rehearsing the ABCs of First Aid. So at the very least, I won't be running around like a chicken with its head cut off when I'm faced with the same situation in the ED. :)

Today, we had an exam where we went through a series of 5 patient encounters, 15 minutes each, for a history and physical. They were pretty basic complaints and I didn't feel like I was unprepared for any of them. Regardless, I was very nervous and I felt the time-pressure. My first encounter dragged out for a long time as I slowly went through all of the steps that I thought were necessary and by the time the overhead said "YOU HAVE FIVE MINUTES REMAINING," I was scrambling to wash my hands and perform some sort of routine physical. I didn't even know what to do, so I delayed by spending some time listening to his heart and lungs as I wondered how to approach the examination. I discussed this particular man's complaint in the parking lot with my friends and I realized belatedly that I should've had him walk around for me. For another patient with abdominal pain, I should have asked her about her menstrual history. It's one thing to post about it... it's another thing to recall its utility under pressure in a clinical skills exam. Oh well.

I left the rest of stations early though, after going through my questions and doing a focused physical exam because I tried to take as few notes as possible. The down side to this strategy was that I found that I forgot a few of the details that the patients had mentioned to me. Ironically, the details that I asked them multiple times always happened when I tried to take notes. Turning my attention away from the patient towards note-taking makes it much more difficult to listen... that was very apparent to me after going through a few of the encounters.

My techniques for approaching the patients and my efficiency went up noticeably as I progressed through the five patients.

That is the best part about this whole thing. Sometimes it feels like a distraction to get all dressed up and come to school to talk with fake patients. But if I'm going to mess something up, I'd rather it be with someone who is an actor than a real patient. I get to refine my skills and structure my interviewing questions in a more systematic format. I have a set of patients that I can discuss freely with my classmates (we all saw the same people after all) without having to worry about HIPAA. Unfortunately, I can't discuss them freely here as much as I'd like to.

Here's my main point.
I spend so much time learning about the science of the medicine... I'm glad that we get to practice the art from time to time too :)