Of Colonoscopies and Sleep Deficit

Another week of Medical School is done. In attempt to stay awake at some point this week I found a website that figured out how many weeks it is until I graduate, presuming I survive that long. It is almost a bit scary. Our course is 145 weeks long, the last 54 weeks are clerkship, we have 8 weeks of holidays and 83 weeks of instruction. Thus, having completed four weeks we have 79 weeks of instruction remaining to learn all that we need to know before we begin our clerkship. Time is such a precious commodity and it is slipping away so quickly. It feels like we just started class the other day but I've now been here for a month and I'm certain that the next 141 weeks are going to go at the same rate and I will be finished.

I've observed that I'm not a very good time manager and one of my biggest challenges is going to bed at night. This is partly a result of daytime procrastination and partly a result of the fact that I'm a night owl. The problem is that we had classes or activities of some description at 8:30 every day this week. That really cut down on my sleep in time and it made it a bit challenging to take anything away from lectures when I was functioning on not enough sleep. I'm quite fortunate though - almost all of the lectures in this course are podcast - they are recorded during the lecture and then uploaded to iTunes where we can download them. Thus, while I write this I am multi-tasking by listening to a lecture about alcoholic hepatitis and non-alcoholic fatty liver disease. This is the second time I've listened to it and hopefully by the time it is finished I'll have got the majority of important points from it.

There are two new words that I'm quite partial to. The first is asterixis - it is a symptom of hepatic encephalopathy and refers to a characteristic tremor of the hand when it is extended. The second is a phrase - scleral icterus and refers to yellow eyes (rather the 'white' of the eye) which is characteristic of jaundice.

Today we watched two colonoscopies. We were in a small theatre in the screening clinic and we watched the procedure via a live video feed. The colonoscopist was miked so she 'walked' us through the colon and a polypectomy. It was pretty cool! We've learned quite a bit about the large intestine but to see it in living colour with the healthy, vascularized, pink colon wall was fabulous. There was a small polyp we watched get burnt off as well so it was fascinating. It is amazing what you can do with technology today. It was also fascinating to see the variation between the lining of the terminal ileum which is lumpy from lymphoid tissue and has a carpet of columnar epithelium that looks like 'shag carpeting' compared to the smooth pink squamous epithelium of the large intestine. The border is very distinct. I've found it quite interesting how precise the borders in the body are. There are visible lines between different tissues at places like the gastro-esophogeal junction at the ileocecal junction and elsewhere. Another rather nifty thing was retroflexion. This is when the colonoscopist turns the tip of the colonoscope back 180 degrees on itself. This allowed the colonoscopist to view the rectal-anal junction (an important spot to check for pre-cancerous polyps) and you could see the scope being squeezed by the anal spincter. The same procedure can be performed during an endoscopy to examine the fundus or top of the stomach and the gastro-esophogeal junction where the esophagus and stomach join.

Anyways, I'm off to a bonfire and a nice sleep in tomorrow. I need to listen to some more lectures and by Monday morning I'm going to know a lot more about Hepatits, Gall Stones, and Liver tests but for now it is Friday night and I'm off.

The Rise of the Blobfish

Orientation is complete, and the class of 2012 now has a name. I am no longer simply a member of the Class of 2012, I am now a Blobfish. As a Blobfish I’ve joined the Class of 2011 (the Kakapos), the Class of 2010 (the Glabers), and others. This is a Calgary tradition – each incoming medical class gets an animal name and it seems like the weirder the better. For your information, the Blobfish (Psychrolutes marcidus) is considered one of the world’s ugliest fish and lives at the bottom of the ocean off Australia and Tasmania, floating just above the ocean floor. It accomplishes this by being composed of a gelatinous substance with a density slightly lower than that of water. Thus they have to expend very little energy to just float along and eat little bits of food that come by. These poor animals are often caught by bottom trawling fishermen and die terribly painful deaths when their gelatinous mass is exposed to the harsh ultraviolet radiation of the surface of the sea!

We’ve now begun another week and I decided I’d better update this blog before life gets too busy. It seems like we tend to have topical weeks. This week is going to be about the liver – liver cancer, liver disease, liver symptoms so I’ll be able to tell you what is happening to your liver by Friday, if all goes as planned.

Last week on the other hand was all about blood and the oesophagus – we had a whole afternoon about three different kinds of anaemia, a whole morning about Thalassemia, and a bunch of lectures about oesophagus cancer and swallowing difficulty. I led my first Case Study group this past week. In our first course we have approximately 22 case studies. In our Small Group of 10, two people are assigned to lead each case study. So, my topic was dysphagia or difficulty swallowing. We worked through the causes and possible diagnoses associated with dysphagia and came up with a differential diagnosis, possible therapies that could be tried, and diagnostic tools that could be used to come up with a definite diagnosis. Each case study has a preceptor who is a physician here in Calgary. Our preceptor for the Dysphagia session was a general pediatric surgeon who was very keen about medical education and has offered us any kind of shadowing experience we would like at the Children’s Hospital so that is a fantastic opportunity I mean to take advantage of.

I am not really aware of the sheer volume of material that we are learning although when I start to think about the volume it is amazing. We have been in class for three weeks and have covered an array of presentations, pathology, anatomy, and therapies already. The overlap and holistic style of instruction is very effective for helping us assimilate this large volume of material but I personally find the small group learning sessions by far the most effective.

Saturday afternoon my Core Group (5 people) met with one of our Physical Exam preceptors. Our preceptor is a resident at the Peter Lougheed Hospital and in these sessions we are to learn how to perform a proper and effective physical exam. We began with an examination of the spleen and the lymph nodes. The preceptor would explain things to us then demonstrate them, then ask us a question about them to make sure we understood. I think it was the most fun I’d had at medical school. We were actually Inspecting, percussing, and palpating a healthy abdomen to see if there was any evidence of splenomegaly. The passion of the preceptor and the stuff we were doing was amazing – it was a great learning experience and I didn’t even mind being in a clinical skills room on a sunny Saturday afternoon.

This morning we are starting with Healthy Populations. While everyone recognizes the importance of epidemiology and population health it is acknowledged as one of the ‘drier’ topics for lecturing and I suspect it will be rather poorly attended as the weeks go by (especially on Monday mornings). However, it is almost time for a break so I’m going to call this all for now. My apologies if this narrative is somewhat disjointed – I’ve written it on two different days and while listening with one ear about community needs assessments so hopefully there are not major mistakes.

Have a great week all.

The First Cadaver and Other Reflections

So I have now completed a total of six days of medical school and it seems like a lot more than that - we have definitely jumped right into the program. That being said we are still being introduced to courses that will run longitudinally throughout the year. Thus far med school has been very organizedly unorganized or perhaps unorganizedly organized. Everyone seems to know more or less what is going on except for the students, that would be me. Like a herd of sheep we simply follow the other 20 year olds that look somewhat lost and have a red backpack. We all got backpacks on free day and they are a great way to recognize a person who you realize is in your class, that you have probably met but have no recollection of ever actually talking to. However, we are definitely learning. I can tell you most of the components of a complete blood count (CBC) and discuss the primary causes of Upper GI bleeds. I also know that you are supposed to hear all sorts of things through your stethoscope, and perhaps one day I'll even know what I'm listening to. The learning curve is steep, and I think next week it will get even steeper.

It may come as a surprise to some but lectures at medical school (of which we have a decent number) are very similar to lectures in an undergraduate degree. You might even say shockingly similar - there are good lecturers and not so good lecturers. People come late, other people (I might add that most of the med class are keeners) show up early. After four hours of lecture it doesn't matter how interesting it is but you are starting to doze off and your focus is slipping rather badly. The up side of these lectures is that they prepare us for the much more stimulating small group sessions. The lectures provide the background and then the small groups provide the reinforcement to make sure you've actually sorted out what you need to know. Our preceptors (doctor teachers) guide our small groups and are actually amazing people at the top of their game! We are also seeing our 'circle' of peers shrink a bit. By the end of the year we are going to know the people in our small group well but the rest of the 180 we simply don't have the inclass time to become acquainted with, that will have to happen outside of class time.

The list of recommended textbooks keeps growing - physical exam texts, general medicine, anatomy, physiology, pathology, haematology, and so forth. If I buy them all I'm going to need another room in my apartment just for the texts. Unsurprisingly these books cost an arm and a leg, but at least we'll learn how to justify an amputation in Course 2 where we talk about the musculoskeletal system.

We are already being inducted into a profession that is by its nature somewhat closed - we are gaining a very specialized body of knowledge that is necessary to do our job. For example in a recent lecture on transfusion reactions - problems associated with transfusions of packed red blood cells, platelets, clotting factors, etc that the public's largest concern is with viral transmission. The spectre of the HIV transmitted to haemophiliacs in the '80s still haunts the public. However, for the medical professional viral transmission, as a risk associated with blood transfusions is down at the bottom of the list of concerns. There is a whole raft of other problems that are far more likely to affect a patient than HIV. The statistics are something like - you are more likely to be hit by lightening than to be infected with HIV from a blood transfusion. Adding to this 'professional mystery' is the jargon that we are picking up. We will learn it to interact with other professionals but when dealing with patients we will have to remember to phrase it in understandable terms. One does not ask a patient if they are suffering from dyspnea or nocturnal diaphoresis. There are a multitude of wonderful terms that are perfectly accurate - exsanguination, hematochezia, hematemesis, polycythemia and yet disguise the problems one would be experiencing or the fear you might feel at (exanguination 'bleeding out'), seeing a toilet bowl red with fresh blood (hematochezia - blood by rectum), or vomiting up bright red blood (hematemesis). In contrast polycythemia (abnormal increase in the number of new red blood cells) seems less severe but also is a symptom of problems!

This afternoon we spent several hours in a series of stations to become acquainted with the anatomy laboratory. We looked at specimens of ulcerated and cancerous stomachs and then examined microscopic samples of these tissues (this is known as histology). This was followed by an examination of blood smears - both normal and abnormal. Then we spoke with some phlebotomists (people who collect blood) about blood typing (determining whether you are A+ or B-, etc) and transfusions. This was followed by our first exposure to a cadaver.

Because of the structure of Calgary's program we will not be following the traditional 'get a cadaver and cut it up' methodology sometimes associated with medical training. Instead we will look at prosections (prepared sections) and other specimens that are associated with the specific unit that we are learning. We will still learn anatomy and physiology but it will not be the traditional independent classes that you sometimes hear about.

The first cadaver I've ever seen was a male - his face and lower extremities were covered and his abdomen was opened so we could see the GI tract which is the topic of our study at the moment. Our excellent anatomy instructor pointed out the various parts of the GI tract, showed us where and how hiatus hernias develop, the various parts of the stomach (where different kinds of ulcers and cancers grow), and then the parts of the large and small intestine. We also discussed blood supply to the guts through the celiac, superior mesentary, and inferior mesentary arteries which branch off of the aorta at the celiac trunk. One thing that struck me is the size of the aorta, especially incomparison to the size of other components of the peritoneal cavity (most of the abdomen). It made it very clear why problems with the aorta are VERY serious. Another thing I noticed is how far into our body the spine protrudes. I tend to think of the spinal column being relatively flat but anyone who has seen a spine assembled (just the bones) knows it is not this way. The oesophagus or esophagus and the aorta run right along the bones of the vertebrae and it sticks up into the thoracic and abdominal cavities separating the various organs from one another. Suffice to say seeing a cadaver puts things in perspective in a way that a text book simply cannot!

Our final station was a discussion of endoscopy. Endoscopys are a procedure to look at the upper GI tract. There is an endoscopy simulator that was used to demonstrate a normal endoscopy and then repair an ulcer - this is a pretty cool piece of equipment (for around $90 000 you should be able to get an amazing piece of equipment)!

Today we received contact information for our Clinical Correlation preceptors. These are practicing physicians that are going to take us into the ward and introduce us to patients who are relative to the content we are learning at present. Thus, by the end of the month we will be interacting with real live patients, on the wards - Med school is COOL!

However, at this point in time this narrative has wondered on for too long as is. My alarm is going to go off too early tomorrow and it is difficult to learn when you keep falling asleep.

Let the learning begin

Words of the Day

Melena: black, tarry foul smelling stool containing blood. The blood is a relatively large volume, has been exposed to gastric acid, has been exposed to bacteria, and has been in the GI tract for 8-14 hours.

Borborygmi: the rumbling stomach sounds characteristic of hyperperistalsis

Today was the first day of real med school, and I'm thinking I might be a busy fellow for the next three years. I enjoyed this past weekend having a bit of time to get more settled in my apartment and catch up on a bit of sleep, another aspect of life that is going to be at a premium I believe.

The picture I've added to this post is of the Foothills Hospital complex. There are technically a whole bunch of individual buildings but they are all connected. I will be spending the majority of my time in the building at the tip of the arrow. This is where the Health Sciences Library, Clinical Skills Centre, Small Group Rooms, and Lecture Theatres are located. Incidentally if I could climb up a very high ladder into the sky out of the roof of my apartment this is the view I would se as well.

They broke us in easy this morning at 8:30 with our Introduction to Medical Skills. This is the class where we will learn about communicating with patients, performing a proper physical exam, taking a history, ethics etc. After a brief introduction we finished out the 2 hour block by watching the film Patch Adams. We will be discussing the various attitudes and methodologies the various characters adopt throughout the film but it was a nice way to start. We then had a break until 1pm when things started for real.

We had lectures from 1pm-5:15pm this afternoon so it was a fairly dense information to brain dump. The topics ranged from how we will be assessed for our first course (which runs from now until October 22), a brief overview of the multitude of lab tests that can be ordered by a physician such as a CBC, INR, GTT, GGT, PTT and so forth. It was meant to be a general overview and introduction and it was! We finished the day with a discussion of Upper Gastrointestinal Bleeding, the first of the 120 patient presentations or ways that a patient could present to the physician (if I understand correctly). The lecture was complemented by a youtube video of an endoscopy of a normal upper GI tract. It starts putting this in a useful, real life context...on the very first day of lectures. This was really interesting and I love the way that the instructors draw on all aspects of a problem to present it. We talked about symptoms, taking a history and what to look for in this kind of a presentation, physically examingin for this problem, the most likely causes, way to confirm a diagnosis, classifications, emergency measures, and treatment. It is a very holistic approach that I think is going to be very effective.

Judging from the volume of material covered today I'm going to be busy. In some ways I was able to float through most of my undergraduate degree with periods of intense effort immediately prior to exams and paper due dates. However, that is not likely to be very effective here considering the volume of material and the importance of learning it well...so I guess a readjustment of study habits may be necessary but only time will tell.

I'm off to make some supper; however, if you are interested in what your hopefully healthy esophagus, stomach, and duodenum look like check out this video on youtube - http://www.youtube.com/watch?v=pNXJdlqYqqc