Medical School 2020, Year 1, Week 10
From our anonymous insider…
With the first exams finished, we are all more comfortable with our roles as medical students. My comfort level rose to the point that I ordered a stethoscope. I’ll be ready for next week’s “white coat” ceremony.
Anatomy this block will focus on the cardiopulmonary system. In preparation for removing the chest wall, we dissected the anterior neck. The carotid artery was huge, about the size of an adult’s thumb, and we could see the plaque that had built up during 97 years of living prior to becoming a cadaver. We got a beautiful view of where the common carotid artery bifurcates, forming an important structure called the carotid sinus. The carotid sinus contains nerves with specialized pressure sensors that regulate systemic blood pressure. A few decades ago, doctors investigating hypertension or shortness of breath would palpate and briefly constrict the carotid sinus to ensure blood pressure changes occurred. However, this can cause strokes from plaque rupture and we learned that therefore the practice has been discontinued, but we haven’t yet learned about modern diagnostics.
Lectures focused on embryology with a patient case of fetal alcohol syndrome. So many coordinated events occur within the first two weeks post-fertilization, it is remarkable how rare serious birth defects are. One fascinating process is how the embryo creates a left-right axis. A region of cells have a single cilium, a vibrating thread similar to the flagellum that propels sperm cells. Coordinated beating of these cilia produces a net leftward current and creates a concentration gradient of signaling molecules to turn on “lefty” genes. We learned about sinus invertis, in which the body is flipped left-right. The condition affects roughly 1 in 10,000 individuals, many of whom have no symptoms at all! We also learned about some more serious cases of birth defects, e.g., sirenomelia (“mermaid syndrome”) where the lower extremities are connected, and encephalocele, where the skull does not fuse correctly and the brain grows outside the skull.
Our patient case involved a teenager whose biological mother had used alcohol, cigarettes, marijuana, and cocaine while pregnant. “Greg” was born with fetal alcohol syndrome and addicted to cocaine. State social services agencies automatically investigate every case of fetal alcohol syndrome and, in this case, Greg was turned over to a foster mother, who was the primary speaker to our class. The foster mother, who quickly became the adoptive mother, told the story of how she came to love this child and the role of her Christian faith in the process. There was a lot of crying and the still-unanswered question of how the biological mother could have done this to Greg. Much to everyone’s later-expressed surprise, when Greg finally walked into the room he was articulate, though nervous, with none of the aggression common to patients with a history of fetal alcohol syndrome. Greg was aware of his history and challenges. He described being frustrated by his poor memory and difficulty learning abstract subjects such as mathematics. However, he enjoyed history and socializing with other students at his special-needs school. We were impressed by Greg’s determination and perseverance, but It seemed likely that he would require lifetime assistance from a responsible adult.
The case sparked a lively discussion on the legal ramifications of drug abuse while pregnant, a matter governed on a state-by-state basis. The spectrum of laws ranges from criminal prosecution if a child is born addicted to drugs or showing signs of fetal alcohol syndrome to no consequences beyond the potential for losing custody of the baby. Some midwestern states are in the middle of this spectrum, with a rehabilitation mandate for pregnant women who consciously abuse drugs and alcohol. Greg’s physician opined that the potential for criminal prosecution was counterproductive because it dissuades addicted mothers from continuing with prenatal care. Women who’d previously articulated feminist positions in the classroom immediately voiced their objections to sanctions against mothers on the grounds that this was a step on a slippery slope toward infringing on a woman’s abortion rights.
Later in the week, three primary care physicians led a discussion on how to approach patients about medications and drug usage. Doc 1 opened with a story about taking her 12-year-old daughter to a specialist. The nurse stared at the computer screen and read the questionnaire out loud without looking at the 12-year-old patient and mother seated nearby. “Do you drink?”, “Do you smoke?”, “Do you use illegal drugs?”, “Do you feel safe at home?” This tale of attempted human interaction in the age of electronic medical records prompted Doc 2 to chime in: “Never trust the medication list in Epic [‘MedRec’] as it is rarely up-to-date, and will certainly not include more sensitive drugs and behaviors.” Doc 3 seems to be a contributor to this phenomenon, saying that he is cautious about adding to a permanent electronic record that is accessible to the patient on request. “I never put a ‘suspected heroin use’ note in the chart,” he said, “I just keep a note on my desk.”
Doc 1 told us to remember that it is not just illegal drugs that are used illegally. She had prescribed a muscle relaxer and prescription-strength ibuprofen (NSAID) for a patient with a back injury. After three months, the patient said that she’d stopped taking the medications because her middle school daughter had been pressured into stealing them by her classmates. When the daughter began to refuse, her “friends” threatened the mother that they would “jump the house” (?) to steal them. Despite the limited potential for getting buzzed off a muscle relaxer, Docs 2 and 3 were not surprised. Lesson learned: lock the medicine cabinet.
Statistics for the week… Study: 10 hours (1-2 hours after class each day). It has been easier to study this block’s organ systems instead of the abstract biochemistry pathways that we were learning in the last block. Sleep: 6 hours/night; Fun: 2 outings. Example fun: drinks and music at Thursday downtown rooftop party and a class happy hour at a local pub.
The Whole Book: http://tinyurl.com/MedicalSchool2020
Full post, including comments