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.

Storytelling

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 :)

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.

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.
Google.

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.

Wow.

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.

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 :)

Connecting with kids

I raced back and forth, darting from exam room to exam room, following the brisk strides of my two peds attendings for the day. It was only a brief moment in time... a single afternoon for only three hours... and I had to meet with my study group right afterward, so I couldn't stay longer. If I could've, I would've.


I love pediatrics.

The first child came from the outer islands. She was a 1 weeker, 40 weeks gestation who got RSV bronchiolitis and she was here for a followup. My attending tried to elicite a few of the primitive reflexes for me, but she was a little fussy. She was a total cutie though!


The second kid I saw came in because the school "nurse" pulled her out of school because of a suspected case of pink eye. I learned that the public school nurses aren't nurses at all, actually.... they just have a bachelor's degree in something or other and then they get recruited to sit in the office and put ice bags and bandaids on kids without any real training! Here in my state, at least. The really interesting thing was that out of this false case of conjunctivitis came a true history of asthma! She was sent off to get a chest x-ray and was prescribed some albuterol and corticosteroids. She had a hard time listening to the directions for the correct way to take her medications... which got me thinking about some of the things I would have liked to do if I were in charge of the patient encounter. First, I'd put her in charge of her care. Give her all of the pieces, the two inhalers, the spacer and have her put it together. I'd have her recite the instructions out loud, practice once without actually using any medication and then again with the inhaler. Instead, it turned into a chaotic shouting match with the pediatrician and the mom telling her to listen. Yikes.

The third kid I saw was a teenager who sprained his wrist while skateboarding. The doctor took an x-ray and found a hairline fracture in the adjacent finger to the one he was complaining about! Turned out that it was dislocated and he reduced it on his own afterward which added to the swelling. The pediatrician buddy taped the two fingers together, his right pinky and ring finger together and splinted it. He didn't like the pink tape, so she went off to find an ace bandage. While she did that, he turned to me and said "good, at least I can still play the PS-II," wiggling his index and middle fingers. When she came back with the PURPLE ace wrap and covered up his entire hand, it didn't go over so well with him. She revised the wrapping to just the two fingers and all the nurses complimented his splint, saying that it looked really cute. The pediatrician recommended taking some NSAIDs for pain relief and he went "what? no, i don't take meds for pain." I chimed in "well, they also help reduce the swelling so your fingers won't be so uncomfortable." "Oh.... in that case, ok." The mom gave me a thumbs up and a knowing nod.

That really made my day.

SAFE Moms Take Really Good Care, others go "AAAAA!"

Antibiotics to avoid in pregnancy:
SAFE Moms Take Really Good Care
Sulfonamides
Aminoglycosides
Fluoroquinolones
Erythromycin
Metronidazole
Tetracyclines
Ribavirin
Griseofulvin
Chloramphenicol


Other serious teratogens that make moms go "AAAAA!"
Alcohol
Anticonvulsants (Valproic acid, Phenytoin, Carbamazepine)
Accutane (aka Isoretinoin, Vitamin A)
Aminopterin
Androgens


References
First Aid for USMLE Step 1
Wikipedia

Life updates.

I've been pretty busy, so I thought I'd take some time to compose my thoughts and share them before they all drain away.

I took my midunit exam today on OB/GYN and pediatrics. It was a good exam, but there were a few multiple choice questions that bothered me. The prompt went something like this:*

So you decided to skip pharm lecture and sleep in, but your conscientious friend pimps you on relevant facts for the USMLE.
1) Which of the following is NOT used for lymphoma?
2) Which of the following is the primary indication for esophageal
cancer?

Here's my beef.... what the heck does this have to do with OB/GYN/peds? What does it have to do with Step 1 for that matter?!? the drugs listed were very specific. We didn't even learn about them during our Heme/Onc cases. I thought it was patently unfair to quiz us on useless information and on top of that, insult us in a passive-aggressive way.

*actual questions modified to avoid Honor code violations, but the essence remains.

------------------------------------

In other news, prepping for Step 1 has begun. I bought Kaplan Qbank and I immediately decided that I didn't like it. The format is slightly different than USMLEworld and the highlight/cross out function doesn't really work. There's no easy way to rapidly review just the wrong answers for an exam you took previously. Still, it's more questions and I'm going to use it (since I bought it) to supplement my learning from First Aid and World.

My approach for studying is slightly different than most of my classmates... everytime we hit something in PBL, I hunt down every possible board-relevant fact about it and try to commit it to memory. Some study groups are hitting up subjects like biochemistry and microbiology already. IMO, that's too early. It's gonna go in one ear and out the other.

The coolest news by far, was the discovery of a FREE Qbank for Step1. One of my classmates told us about it via the class listserv... here's what she had to say:

Ahoy board studiers! I'd like to pass on a resource - it's a free step 1
test bank written by 3rd & 4th year med students. Some facts:

* Free and always accessible
* Questions reflective of Step 1 because they are written by students who took the test
* Good explanations with right and wrong answers emphasized
* Links to wikipedia for more info (provided in answer) - and everyone loves wikipedia!
* Lots of features like qbank where you can look at your results and how you compare to others, flag questions, create personalized tests, etc
* NMBE practice questions too

I think it's pretty cool that a bunch of med students are working together to provide a completely free test bank, and one of my friends (4th yr @ Mt. Sinai) writes questions for it.

Hopefully you find it useful (more questions = better)

One word to sum it all up.

A lot of learning in medicine teeters upon this point of tragedy and education. After all, it is only through the sick misfortune of others that we learn our craft. It ties me up inside to be excited when I see someone with a rare disease that I learned about only a few days before... or to finally understand the mechanism of a medication that will limit someone's lifestyle for many years to come. The cost of these things is often times too much to bear on the cold side of the stethoscope, yet they can be treated so cavalierly from an objective, learning standpoint.

After playing around with a few words with a friend, contemplating "tragimarkable," "remorsexciting"... I settled on my vocab word to sum it all up.

Terribleriffic:
Terrible and Terrific encompass both ends of the sad/exciting spectrum of medicine into a single word. It has the additional advantage in colloquial use by emphasizing different parts of the word.

I think this word is very versatile and it will serve me well. :) IIRC, graham @ overmymedbody! had a similar idea, but I can't for the life of me remember what his word was.

Don't be MEEC about Aseptic Meningitis

There's no need to be "MEEC" with your differential diagnosis for aseptic meningitis! Here's a mnemonic to help you out.

Mumps virus
Echovirus
Enterovirus (like polio)
Coxsackie virus

If an infant comes in with a stiff neck, altered mental sensorium, irritability and high fever, get some CSF. If it's clear and fluid analysis shows elevated protein, but no decrease in glucose and high lymphs... think aseptic meningitis. Bacteria would make it cloudy and eat up the glucose.

Meningitis is one of those critical ER diagnoses. Don't hesitate or the baby could die! Unless its viral, then there's not much you can do but provide supportive care until it resolves. :-\ Herpesviruses and varicella can be treated with antivirals.

Step 1 Starts Now

Thus begins my journey into the gaping maw of dread and doom.

It is time to begin studying for the Step 1 US Medical Licensing Examination, ironically abbreviated USMLE (which most second year med students DO NOT smile about.)

We selected out dates to take this exam a few weeks back. Everyone traded notes and talked about which subjects they already covered and what they were going to cover. A lot of this happened in secret, since our curriculum directors wouldn't be happy to hear that we're studying something aside from their material. My medical school is very different in its setup from other schools. I hear that other students are groomed to take Step 1 the moment they enter medical school. We are groomed to learn clinical and problem solving skills, do research and present it effectively to small groups. I strongly believe in the PBL curriculum but even I'll admit that it doesn't leave much time for the board exams.

One of the things that caused me great anguish was that my brother was graduating from college in the middle of board studying time. Right after he graduates, my parents, his girlfriend and her family are all planning on going on a nice family vacation.

What about me?!?!
I've got this HUGE exam that I'm recommended to take on the week of the 27th of May, the day after my parents return from this awesome family vacation. The score from this exam plays a role in determining where I go for residency as it sums up pretty much my knowledge base for the first two years of medical school.

I reluctantly declined the invitation, choosing school over family. One night, when I was cleaning out my car, I glimpsed at the itinerary that my brother's girlfriend, J, has "forgotten" there. They were going to the Grand Canyon, Las Vegas and Bryce National Park... WHAAAT?!?! I've always wanted to go to the Grand Canyon!!!!! DANG IT

I thought about it and I realized that it would be the LAST family vacation I'd be able to take with all of them.Very painfully, I reluctantly withdrew my resignation and decided to accept instead. J squealed with happiness and they both agreed to do whatever it took to support me (and help me pass my Boards.) Don't know how they'd do that from California, but whatever.

I do have one thing in my favor for taking this exam two weeks earlier though. We took a practice exam in October and I somehow managed to pass that one with a 66/190. I was one of three people (that I know of) in the entire class who pulled that off without even formally studying for the exam! I figure that I must have retained some of that brilliance.

Hopefully.

Chatter and silence

There was a delightful amount of chatter in our classroom three weeks ago as everyone converged for our first lecture of 2008. Fresh from winter break where many people went abroad, friends reunited to share their holiday events with each other.

Strangely, I found myself in the midst of this exchange of excited words and gestures with my nose buried into the papers of the day's lecture notes and the future lecture schedule. I found this surprising... normally, I'm very talkative, but I didn't feel like participating in any discussions. I felt lazy. I felt unmotivated. I felt blase and boring.

Was I turning into an introvert?!? Last semester, I had to study nearly 10-15 hours/day without any breaks on the weekends just to keep up with the material. Neuroanatomy, Half of Robbins, Neuropathology... that was the "bonus" material we had to study in addition to the typical case material and Anatomy/Path labs. 10-15/7 (almost 24/7, accounting for food, sleep and bathroom breaks) left very little time for socializing. When it was over and winter break started up, I felt very burned out. I didn't want to call up my friends to hang out. I slept in until 11 or 12 on a regular basis, just because I could. I wasted as much time doing as little as possible. Looking back, it was a reaction to the pending realization that THIS would be the last restful break I'd ever have.

I heard the horror stories of third-year clerkships. I knew about the restless nights of being on-call.

I withdrew into my shell.

Now, I can honestly say that I am breaking out of that shell.
I've moved into town so I'm closer to school.
I've got myself an outgoing upperclass roommate.
I've been sticking to my resolution to spend more quality moments with my family, having dinner, playing games, talking, etc.
Heck, I've been going out twice a week! Whoa... that's pure heaven for the typical med student. The downside is that I feel like I'm drinking a lot of alcohol. I'm a social drinker (read: not a big fan of EtOH, but succumbs easily to peer pressure). Guilty pleasures, indeed. I've met a lot of new people and old friends in the past three weeks that I feel happier now than I ever did in my first year of med school.

That's not to say that I wasn't happy before... but I definitely wasn't taking care of my "goose" as much as I should have. (FYI, UH med school has a running gag about caring for your "goose", so it continues to give you golden eggs.)

A part of my neglectful goose has been this blog. I'm sad that I posted more as a pre-med than as a med-student.

The silence ends now. I'm going to reorganize this blog and turn it more into a commentary on my life. I'm going to make myself more transparent. No more "pseudo-anonymity" from me! I'm going to be participatory in my favorite feeds. It'll mean more work, but I want to contribute to the cyberverse of medicine and such.

OLD PAM's menstruation

Sometimes, young women are reluctant to talk about their female problems. It is important for primary care physicians, then, to ask OLD PAM some screening questions about her menses.

Onset: When did your menses begin?
LMP: On what date did you last menstrual periods occur?
Duration: How often do your menstrual periods occur? How long do they last for?

Pain: Is there any pain associated with menstruation?
Activity: Are you sexually active?
Meds: Are you practicing any form of birth control?

Questions gathered from
Seller. Differential Diagnosis of Common Complaints. 4th ed. 2000. (the purple ddx book)

Cold Shock

My watch went off at 6:30am this morning and I toyed with the alarm to give myself another 15 minutes of respite before my blessed winter break ended. Ugh. Fifteen minutes can pass by all too soon in the flashes of REM-lidded sleep. My dreams fled as the bleary edges of reality set in. I needed a shower to wake up.

My feet slid across the carpet, licking the polyester edges and I gathered up a towel, soap and scrubber.

FOOSHHHH.
waaugh!!! frick, that's cold water. i would have sworn if i could, but the chill knocked the breath out of me. i slammed the water off and toyed with the knob some more. was there some sort of trick to this? at home, the solar water heater takes a while to heat up the pipes. i tested it again. ice cold.what was i doing here?!? i've got hot water at home. is it really worth trading in a 30-45 min drive to school everyday for this?!?

i felt unprepared to move out of my parents' home all of a sudden. perhaps after close to two decades in the place, i had grown accustomed to everything. i couldn't tolerate the changes. the reason i was tired in the first place was that i was tossing and turning all night in this new, empty cottage. this foreign place i staked a claim for as if it were my own.

with the water a bare trickle, i focused on the sensation. describing it.raw nerve endings tingling, sending salty electrical signals up my ALS. What does that stand for? Amyotrophic, Lateral Sclerosis aka Lou Gehrig's.... but that was a different ALS.
What? oh yes. anterolateral system.
erector pili muscles across the entire surface area of my body strain in unison to raise the hairs on my body.
my skin puckers and quivers from the cold shock of the water.
my body quakes violently to burn excess ATP, wasting energy to generate excess heat. it just makes me feel more like a fool.
the anterolateral system conveys signals of pain and temperature. sometimes it doesn't tell you which one.

as my medico-scientific perspective unfolded, the water grew more bearable. was it actually getting warmer? i couldn't tell... i already finished my shower.

maybe i could get used to living in a cottage as well, parents or not!

Homework setup

I just moved into a new place in downtown near punchbowl. I went shopping for a desk and office chair for my room (the old one was too big) and I found this great computer desk by orispace for only 90 bucks @ Fisher Hawaii!
I like the multi-tier corner idea; it really clears up the room. Dual-monitor setup allows me to surf the web or pull up a journal article on one screen while I work on the other.

[edit] Typing on a cell phone keypad with word guessinng leads to some delays and spelling errors... not sure if I'll continue to use this blogging method, as accessible as it may be.

A Man of Principles

Perhaps it is because of the intersection of my free time, my "expertise" in the health field and my selection of friends, but I had multiple encounters with the charged topic of politics today.

#1) I was in a chatroom with some friends on AIM and someone linked to a blog entry discussing Christmas. In it, the author (a friend of my friends) said "if I were rich, I'd like to take in lonely people and feed them to let them know that not every rich person is a cold-hearted bastard" (or something to that effect.

One of my friends replied (with some degree of underlying hostility, probably fanning the flames of some old argument) and quoted the author's position on universal healthcare and said "no wonder there are depressed and lonely people; they don't have access to mental health services! rich people prefer to buy them dinners to feel better about themselves rather than pay taxes to help them." Whoa!

#2) While I read this exchange, my mom knocked on my door and said "your brother wants to talk with you about healthcare and tell him why Hillary has a good plan (and Rudy doesn't.) Obviously she doesn't have an opinion on the issue. :-\ I'm completely incompetent on this issue, so I talked about basic principles of governing with my brother to feel out his position on capitalism, its values, the role of government in serving its people, what society should do to support itself and the questions he should be asking.

A few things emerged from these conversations.
I boiled it down to two questions:
"If you had money and power, who would you help?"
and the follow-up question: "who is 'not deserving' of this help?"

What I look for in a leader is someone of principles. What does that mean? To me, it means someone who can tell me what their philosophy of governance is and is consistent with my own views. Someone who would answer question 1 with "Everyone!" and #2 with "I don't know."

I'm going to go out on a huge limb here and tell you my idealistic, blazing future for America that fixes all of our woes as I know them, in my completely zany worldview.

First of all, I think that capitalism plays up the wrong traits for a functional society. It breeds smart, cutthroat people who care about success and sneak by with as much as they can get away with. People who don't buy into this philosophy don't rise to power, whereas a true democracy would speak out for the rights of the impoverished and disadvantaged over those of the rich and powerful. Everyone deserves a chance at an equal footing and in this day and age, that applies to healthcare!

Secondly, I think we've got the priority of our National Budget all wrong. A large chunk of our spending goes towards "Defense" when it could be better spent on Education, Health Care and Science/Research, in that order, with defense and everything else following that. Having a core of healthy, well-educated individuals would go far. What would we do with our military that would suddenly be out of a job? I'd make them part of our new Peace Corps. They'd be "invading" other countries with education, like missionaries without the religious agenda. It'd be a share-the-wealth-and-spread-the-goodwill-agenda. Building up relations, networking and if necessary, make a few bucks here and there.

Immigration policy would be relaxed because I'd like to have people cycle through to become trained. They might even be inspired to become a part of the Peace Corps so they can return home and better serve their friends and family back home.

Social security is a difficult subject ethically because the better that our health care gets, the more of a burden we develop with this. I don't think we should ignore senior citizens and delegate them to the "useless waste of money" category. They have proven their worth to our society and they can still provide value! We just need to find more ways to keep them connected with society so we don't see them as a burden on our tax dollars.


I've got more insane ideas. They need to be better honed, because I feel like I'm starting to spout off garbage already...

Goo-ey game

This game sort of reminds me of an amoeba battle. It makes sense, since that's the name of one of the skins the goo can wear.



If I had any programming skills, I'd make a game that mirrors the microscopic environment. It'd be cool to play a game based on immunology for example... it has all the classic elements! You've got your alien invaders (bacteria) that you have to detect (via antibodies and the complement cascade), and destroy (via lytic enzymes and free radicals released by neutrophils and macrophages.)

Besides, the more elements of immunology you add in, the more realistic and educational the system would be.

I'm not sure what the controls would be though. It's a completely autonomous system within our bodies (despite whatever Airborne or other immune-boosting products claim)... aside from the simple factors of nutrition, rest and stress. Perhaps the whole point could be to construct a reliable immune system that can fight off a variety of immunologic stimuli without getting any autoimmune diseases. Ooh! There'd be special levels for TB and HIV for sure. Maybe a few penalties if you accidentally induce lupud following an EBV infection.

Yeah, I'm a total dork. Gamers are dorks too... maybe it'd give a pre-med an excuse to kick it and play Immunology! for a few hours every day to unwind.

Stumbled upon through:
http://www.kloonigames.com/blog/
(home of the awesome crayon game!)

Hypnotic Wasp turns Cockroach into a Zombie

As an undergrad, I worked in a bug lab working on gene sequencing of very rare moths, indigenous to Hawaii (found no where else.) In my searches for press releases on one of our projects announcing the discovery of a carnivorous caterpillar, Hyposmocoma molluscivora, I stumbled across the wealth of science information found on blogs like Pharyngula (the top hit for H. molluscivora) and The Loom. Carl Zimmer posts about nifty parasites and I always felt that this story takes the cake.

Stedman28 review

My parents got me an early xmas present ... a new phone/PDA! I'm thrilled about it; it has a camera and email and all that jazz my original nokia block phone did not have. It also means new programs! I'm shopping aroung to find medical software for my Windows mobile and I noticed a lack of critical reviews on a lot of things. Reading reviews like "THX SO MUCH OMG" and "I love this program! Keep up the great work!" are nice and all... but very uninformative.

I thought I'd do my blogger duty and contribute my opinions to the all-powerful google cache.

---------------------------------

My first review is on my most-used program on my old PDA... Stedman28. It is the 28th edition of Stedman's dictionary and I purchased a cool combo of hardcover book, PDA software and accompanying spellchecker last year. I don't remember the price, but it was WELL-WORTH it. Just having the spellchecker makes you seem more intelligent; spelling out words like chondrocalcinosis or progressive multifocal leukoencephalopathy with autocorrect is beautiful.

The nice thing about Stedman28 is the simplicity of use. Just write out the word and it flips through the index until it finds the one you're looking for! The definitions usually match up with those from the electronic Stedman's Medical Dictionary for the Health Professions and Nursing 1.0... so the hardcover book had a few more details (and pictures!) of items not included in the e-version.

Now for the critique.
Stedman28 takes too long to use. Here's the steps I have to go through to get my definitions:
Since my 1 year subscription expired, I get a message that says:

"Stedman expiry status: your subscription expired on 06/27/2007. Please renew
now for continued access to product updates and Skyscape support.

I have to click a red x to move through that alert message. I don't like the renewal model... when I buy a textbook, the first page I open up to doesn't say "sorry, you've owned this book for more than a year, please buy our new version"... why should it be any different with an e-book?!? I don't want my programs to harass me.
Then I have to select the correct word list index. As you can see from the above graphic, the menu is split between the A-L and the M-Z list. If you are in the wrong index, i.e. searching for the word "neuron" in the A-L section, it chirps at you a bunch of times as it scrolls all the way to the end of "L."
If I search for a word like "NANC neuron" or "motor neuron," it takes me to the broader definition of "neuron" and then I have to scroll down the list until I find the correct word. Sometimes this can take a long time because of the number of words clustered in the list.

I give this program an B+. I have never had any technical difficulties and the word list is impressive. There are a few eponyms that it misses, but those are easily caught by the Eponym program (review to come.)

All done!

After a few months of grueling studying (and a week of being completely BURNED OUT and neglecting studying), I finally finished my week-long set of exams.

The tests were challenging and fair... in the sense that we were given advance warning about the material we would be tested on (unlike the year before us who found our mere weeks before their final that the first 10 chapters of Robbins was going to be on the exam.) I got high marks in all sections, which pleased me. Apparently taking a few days off to just veg out right before the exams didn't hurt me as much as I feared... in fact, it probably reinforced my knowledge-base. I didn't dig out my notes or learn new materials during the past week. Instead, I kept reviewing the things I already knew. It was a good feeling to be so prepared; even though the written essay exam threw a bunch of curveball material that I had to struggle to recall to get partial credit on.

So, where do I find myself during the first weekday of my three-week long freedom?

At school, of course!

Gah. It's not as bad, nor as shameful as it may seem. I have put a research project on hiatus during my finals studying and the lab assistant who was helping me out recently left the lab. I've got to pick up my old project again! How horrible. ;)

Today we had a seminar by a visiting professor on Alzheimer disease, focusing on beta-amyloid proteins effects on neurons. The cruz of the matter is that people with Alzheimers get these plaques of junk (aka beta-amyloid) that cruds up in our brains and messes up with the connections. The professor made the argument that beta-amyloid had a normal neuro-modulatory function in the brain and cautioned against treatments that would reduce levels of beta-amyloid.

This was a big surprise to me. I don't know much about the molecular pathology of Alzheimers... but I thought that amyloid was a waste product, an abnormal process. beta-secretase function predominates over alpha-secretase function for the dysregulation of neurotransmitters in AD!

I asked him a question about the normal function of alpha-secretase and he said that the protein produced is much smaller and it doesn't have any effect. To me, that seems to imply that the normal brain doesn't use amyloid-precursor protein for any positive function, but hey. I'm not a researcher in his field and I didn't want to say "huh? why do you think it has normal physiological functions then?"

I'd like to poke around and do some research on this, but judging by the crazy slides of graphs and his talk about knockout mice missing different nicotinic receptors having strange dose-response curves... I'm not sure I could follow that level of technicality.

One of the things I've learned through my research experience is that I enjoy asking the big questions. Research is something I admire, but I don't really have the lab skills and temperament to enjoy it on a long term basis. Still, I'll be coming in this week to summarize my lab results thus far and start finishing up my experiment. Wet labs are fun, but my goodness! They are SO stressful too! I had an experiment get pushed back a full MONTH because of difficulties with malaria parasites and blood and the lab equipment... it felt like the whole chain of protocol was breaking down piece by piece and we chased after it until everything died and we had to start all over again.

Sorry about the long post. It's been a while since I last wrote and I have a lot to say. I've got more thoughtful things on queue, but these are the things that have been on my mind.