Layers

As time passes, certain events are encoded into memory.  The slightest stimuli unleashes a flood.   A waft of fresh-baked cookies triggers fond remembrances of home; the sound of rain on canvas, camping trips.

It is our collected memories, and our perceptions that stem from them, that are the core of ourselves.

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Classical music is an obsession of mine.  I have played the piano as long as I can remember and I do not go a day without listening to it.  While studying I prefer Glenn Gould's Bach - the Goldberg Variations are a particular favorite - but while taking a long drive I prefer Rachmaninoff preludes.  I made the mistake of listening to Violin Partitas almost exclusively while studying for Step 1 and I fear I may have ruined listening to them for ten years, at a minimum. There is a reason that people still listen to classical music even though the composers are long dead:  classical music taps into the depths of human experience.  (What was the top song of 2006, again?)  I listen to the same works over and over again.  When I hear the Beethoven symphonies I can tell what's happening next; with his piano sonatas, I hum along. 

As a consequence of listening to the same things over and over again, they have acquired layers of meaning.  I reserve the 4th movement of Beethoven 5 for moments of triumph.  Walking out of an exam I listen to it nearly every single time.  Brahm's Intermezzo in A is saved for decompression - when I want to sit back and relax after a long day of work I close my eyes and let the sound wash over me.

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Today I discharged a man to palliative care.  It was the first time I've done this.  He had a long and complicated stay in the hospital - over the fifteen days of his stay he was cardioverted, delirious, and sent in for an embolectomy secondary to critical limb ischemia.  Delirium imposed on his history of paranoia and dementia made him what the interns call a "rock" - someone who is staying on our service for a while due to the fact that no other place will take him.  Late in his course his oxygenation started to fail and he developed a wet cough, secondary to his failing heart and a month and a half of not eating.

As I went in his room to say goodbye he had a rare moment of lucidity.  I took his hand and started to say goodbye.  He looked at me, in between coughs with naked fear in his eyes, and said "Am I going to go?"  Not "go" in the sense of leave the VA, go permanently, as in die.  I did not know what to say.  I had no comfort to offer him, save that he was going to a place where they were able to take care of him.  How utterly inadequate I felt.

While I was sitting in the room blaring in my head was the opening to Mozart's Requiem; the ponderous d minor opening was playing as I was holding his hand.  The crescendo to the haunting entry of the baritones sounded as I left the room.

Requiem aeternam dona eis, Domine. Grant him eternal rest, Lord.

A new layer has been added to the work: the sight of an 86 yoM with a pmhx of dementia, paranoia, Parkinson's, and CHF being put on a stretcher to go and die.

I'm back!

As it's a new year, I thought I'd give another crack at it.  Previously my posts have been a bit more themed; I  think that I'm going to switch things up and go for a more free-form approach to blogging in hopes that it will result in more posts.  I'm not going to be writing for anyone in particular this time, just for myself.

1/4

Well hello!

M1 is officially over.  It's an odd feeling, knowing that I'm not going to have to sit through another lecture, open up the quizzes/exam window, or sit in the LRC for prolonged periods of time for two months.  To be more accurate, it's a marvelous feeling.  The year has dragged on.

Tomorrow I am leaving for Kenya - the next big adventure.  But before I go to Kenya I am visiting my friend Kathrin in Germany first!  I could not be more excited!  After 5 days in Germany I'm flying down to Meru, Kenya, to work on a community health survey looking at Long-term disability due to trauma from roadside accidents.  What I am most excited about, though, is that I'm going to be living in a manner completely different than I have ever lived before.  It will be good for me.

But it's late and I've got to play the piano at church tomorrow - I'll write a couple of times when I'm down in Kenya!

On an unrelated note, I'm 1/4 done with medical school! WAHOO!

John

Bugs and Drugs!

Well hello!

I'm smack dab in the middle of the Infectious Diseases.  Up to this point, it's been the most intense sequence.  We've got required small groups every morning (gasp!) about the lecture material from the morning, which starts at 8.  What this translates to is that I'm once again going to class instead of watching the videos from the lecture.  It's rather nice, seeing people and not staring at a screen all day.

Reflecting back on the year, it's interesting to think about how I've changed my studying habits.  Up until this sequence I've "diagrammed" out the lectures, making elaborate webs of connections.  With this sequence, the process became too inefficient.  It took me around an hour to draw out the map on a piece of paper, which simply doesn't translate if there are four hours of lecture in the morning.  To make a long story short, I've gotten on the flashcard train, and couldn't be happier.

I've been using a website called flashcardexchange.net which has been very handy.  If you'd like to try your hand at learning some of the bugs and drugs, here are my flashcards: http://www.flashcardexchange.com/user/view/840692?view=mine&q.

Another way that my study habits have changed is I've forced to become creative in my memorizing.  We've got many different kinds of drugs to learn and every single side effect of every single kind of drug is important - I'm going to be prescribing these drugs someday and don't want to harm someone.  The volume of the material is too large to just use normal materials, so I've turned to the technique entitled "the memory palace": http://en.wikipedia.org/wiki/Method_of_loci.   What I've done is used the upstairs of my house in Zeeland as a location for memorizing the drugs and their side effects.  For example, the boy's bathroom is used to memorize the antiviral drugs and the guest bedroom is used to memorize the Tb drugs.  Within each room there is a person representing a particular class of drugs within the broader subdivision who is exhibiting all of the side effects of the drugs.  In the Anti-Tb room there is my classmate, Isabel, who has is in a wheelchair, has a t-shirt that says P450 with a slash on it, and is clutching her upper right quadrant of her abdomen.  She represents the ISoniazids, which can cause dose-dependent peripheral neuritis (often manifested in weakness of the legs and arms), inhibition of the P450 enzymes, and hepatotoxicity.  I've done this for every single drug of this sequence; it's a full house.

But it's an exam week, so I've got to get to studying.  It's the last week of infectious diseases; I'm ready for the break from the intense material.

On another note, I leave for Kenya in 27 days! WAHOO!

Cheers,

John

We are fearfully and wonderfully made

Well hello!

If my cell phone is correct (and it usually is) it is already March 25. School started on August 1 and ends on June 1. I have been in class for 237 days and have 68 more to go. This means that I am 77.7% done with M1 year! I've said it before, but feel the need to say it again: time flies.

I've moved onto uncharted intellectual territory: the central nervous system. In my life I've never taken a course on how the nervous system works, so everything I've been learning has been new and exciting. To summarize, the CNS is nothing else than a giant conduit for information in the body, and the amount of information that is sensed, transported, integrated, and stored is nothing less than astounding. Little molecules (ions) flowing into channels (voltage gated sodium channels) travel on highly specific paths (tracts) to a certain area of the brain (nucleus) where the information is then registered, and if necessary, an action is performed.

The bulk of the work for CNS has been learning about tracts: where they originate, what they carry, the path that they travel through the body, and where they terminate in the brain. By my count we've learned more than 15 of these All of these connections are what make seeing this computer screen possible, reading and interpreting what's written, breathing, and everything else that we do.

Another more challenging part of the sequence has been neuroanatomy. Anatomically there is more going on above the neck than there is below, and all of this material is condensed into a 3 week period. Here's a picture of some of the nerves of the face:

Someone else puts it better: we are fearfully and wonderfully made.

Along with the advent of spring better weather has arrived. It's been nice to see everything come to life; on my walk home there are flowering trees in bloom. Studying, however, has become more difficult because it's tempting to go and take a walk rather than memorize the tracts of the neural system. I solve this problem by sitting in a chair that does not face a window: out of sight and most of the time, out of mind.

On an aside, I'm going to see the Hunger Games movie this afternoon with people from my community group at my church. I'm excited!

Cheers,

John

Concentrated misery vs. Prolonged discomfort

Well hello!

Much has happened since I’ve last written. Two big weeks happened, one after the other.

First and foremost, I had my last ever spring break. Back in December I received a mass email sent to the entire M1 class seeing if there was general interest in going on a cruise. To make a long story short, there was. There was a ridiculously good deal on a 4 night cruise to the Bahamas from Port Canaveral, and seeing as it was my last spring break and I have never been on a cruise before, I sprung on the deal.

I ended up driving down to Florida with three other classmates, David Giles, Heather Schofield, and Ravi Chopura. We camped on the way down, which was probably my favorite part of the trip.

Playing Euchre in the tent.

In Tennessee hiked a section of the Appalachian trail going through Great Smokey Mountain National park to a point called Charles’ Bunion. It was an outcrop that had a great view over the rest of the park, which was exceedingly beautiful, even in winter.

Charles Bunion, Great Smokey Mountain NP

The next day we camped on the beach near Jacksonville and I saw one of the most stunning sunrises I’ve ever seen over the Atlantic. (On a side note, I’ve decided that I’m a bigger fan of sunrises than sunsets. While they are early in the morning, sunrises cause the earth to come alive and sing with color, rather than having the color die and fade away into darkness.)

Sunrise over the Atlantic. Little Talbot Island SP, FL

On Monday we finally got down to Port Canaveral and boarded the Monarch of the Seas. Cruises are an interesting experience, one that I’m not sure that I’d like to repeat. Yes, it was nice having gourmet food all of the time and not having to think about where one will go next, but at

the same time, the entire experience feels contrived and artificial. Everything about the entire experience feels (and is, in fact,) manufactured. Additionally, the entire trip felt like one big money trap. Pay to get your photos; pay to have an excursion on shore; pay to have soda for the week. In life things cost money and I’m more than willing to pay for them; I just don’t like the feeling of having products pushed down my throat nearly all day. To me, getting in a car with a tent, going someplace that is relatively remote, hiking, and embracing the rest found in silence and solitude is much more relaxing than sitting on a boat in the sun.

All of this being said, I still had a fun time on the boat, entirely due to the fact that there were 50 other medical students on board. (This is not a type-o. There really were fifty.) Getting to know people who I haven’t talked to before was a good experience.

Going snorkeling!

I’ll share a brief adventure from the trip: my excursion into Nassau. To give the story a bit of context, the boat leaves at 11:30 PM, whether or not everyone is on board. At around 7 some friends and I made the decision that we were going to find a place in Nassau called the “fish fry” – a strip of restaurants offering locally caught and prepared fish. So, we found the fish fry, which was around a 20 minute walk away from the boat. The food was absolutely delicious: I had conk fritters, conk salad, and deep fried conk. After a marvelous dinner that lasted two hours, it was around 9:30, time for us to start heading back to the boat. En route we met some other medical student friends who were in search of a jazz club, and I made the decision to join them in their search. It ended up being 10:30 by the time we found the jazz restaurant, which was another 10 minute walk away from the boat. (At this point, I was starting to get a bit nervous…)

The jazz was absolutely astounding. It was an open mic night, and the entire band was incredible. I’ve never heard such marvelous live jazz in my life. In the second song a friend of mine from medical school, Sam, played jazz guitar with the band – it was a special experience. At this time it was around 11, and was far past the time that we should have left to get back to the boat. Fortunately for us, there was a woman from the Bahamas who gave us a ride back to the boat. As we were running up the pier, workers were making preparations for the boat to leave - talk about a close call!

Another special experience on the boat was I was able to give a piano concerto to my classmates, late at night in an empty auditorium. It was marvelous to share music with people again – I truly miss playing the piano for others.

On the way home we drove straight through. We left from Port Canaveral at 9 AM and got back into Ann Arbor at 3 AM. If given a choice, I will always take a concentrated period of misery rather than a prolonged period of discomfort.

The other “big” week was tech week for a play called the Smoker. The entire idea of the play is to gently poke fun at the faculty and medical education in general. This year I was Dr. Kevin Tremper, head of Anesthesiology. The plot was based on the story of Robin Hood, so the title of the play was “Thrombin Hood and his Merry Meds”.

Rehearsal for the play was every night this past week from 5:30-11:30. At the beginning of the week I was diligent during rehearsal – instead of watching the show I kept up with the material. However, at the end of the week I decided to watch the play throughout rehearsal, so I have my work cut out for me during the next few days. (Again, I would rather have a concentrated period of misery rather than prolonged discomfort.)

All in all, the show was a big hit. Everyone involved, from the musicians, to the writers, to the directors, to the actors, were all incredible. The amount of talent outside of academics here at Michigan is astounding. Yet despite how much fun it was, I am very glad to be done. It will be nice to have my nights during the week unencumbered by rehearsals.

On an aside, the alphabet soup of Immunology has started. CD28, TAP, Tregs, Vabs, Ras, CDR, ITAMs, ALPS, CCL18 and so many more little acronyms will be the exclusive content of the next few days. Yet despite the amount of acronyms and studying that is ahead, I look forward to working hard. I am doing what I want to do.

Cheers,

John

The Calm Before the Storm

Well hello!

I am currently writing from the middle of a CFM week - one of the weeks where I get to actually feel like a "real" doctor. The two big tasks this week were to learn the abdominal and musculoskeletal (MSK) physical exams. The former is rather simple - you look at the abdomen, listen to it with your stethoscope, percuss it, and finally palpate. As long as the person doesn't have a big liver or spleen, they're generally OK. For the MSK exam all that one does is go through each joint of the body, move it every which way, as well as try a few specialized tests for the rotator cuff, cruciate and collateral ligaments, and the menisci. Although it seems brief, what I've just written is the distilled essence of both exams, simple and straightforward.

With all of my extra time this week I've taken the time to connect with old friends (I chatted with Daniel Ericks, one of my best friends who I've known since preschool and hadn't talked to since November), spend time with new friends (last night people came over - we played N64 and board games), and catch up on sleep (the past two days I've taken "strong" naps - 2.5 hours long!)

Additionally, tomorrow I am leaving for Spring Break. Around 45 medical students are going on a 4 night cruise that leaves out of Port Canaveral, Florida. We're going to be heading to the Bahamas. I've never been to the Caribbean and have never cruised, so I am quite excited. Don't worry - I'm packing plenty of sunscreen. I and a couple of other friends are roadtripping down, camping along the way. We're stopping at Jones Gap, SC as well as Little Balboa Island State Park. Here is our route:

Yet after Spring Break is over, that is when the real work of the first year of medical school begins. I am currently enjoying the calm before the storm. We have the hardest three sequences all in a row: Immunology, Central Nervous System, and Infections Diseases. The last is particularly notorious - a 5 week long crash courses on bugs: viruses, parasites, and bacteria. I'm looking forward to the challenge.

On another note (or more like 88 notes...), I've finally tuned my piano! Instead of paying a tuner, I bought the wrench (for less than it would have cost to have the piano tuned) and did it myself. (Even though I do not live in West Michigan anymore, I still cling tightly to my Dutch roots!) After 7 hours of tinkering (misery?) and one broken string later, the instrument is finally in tune! I've started learning a new piece: Earl Wild's transcription of the Gershwin song Embraceable You. If you click on the following link, you'll hear a bit of what I'm hopefully going to sound like: http://www.youtube.com/watch?v=7D4nocoFeJM&feature=related

Cheers,

John