The Importance of Clarity: A Story

Today is fibromyalgia awareness day. I find it quite apt that this happens the day before Mother’s Day.

For as long as I can remember, my mom has suffered from pain. She has always been particularly sensitive to noise, bright lights and abrupt touch. It was only when we were little and clumsy that it didn’t seem to bother her. An overriding maternal instinct I suppose.

I inherited my migraines from Mom. I remember trying to occupy my little sister and baby brother when I was eight and nine, because Mom was in pain and I wanted her to rest and feel better.

 

I remember waking up in the dark hours of the morning with all the lights on, finding that our help had been asked to babysit us in an emergency, so that Mom could go to the ER for pain management. She had severe backaches.

I remember there were nights when Mom went to the ER twice, in tears. Returning with no more than a diclofenac injection.

Mom’s pain is one of the reasons I have trust issues with doctors. For more than a decade, while Mom had exhausting and debilitating pain, she was not referred for a single X-ray. Her hands, swollen with osteoarthritis, were not looked at. She was told, “Ma’am, it could be so many things.”

As if that was a reason not to do a pain workup.

When I came to med school I became more and more convinced that Mom needed a better doctor. Little by little I learned new things: backache is bad. Night pain is bad. Patients deserve a diagnosis.

Last year we learned about fibromyalgia. And I knew, this was it.

In early January, while I was home for the holidays, Mom returned from shopping in tears. She was in pain again. I took her to the new doctors’ complex in town and made an appointment with the youngest doctor on duty.

She was from a school I trust. And I trust the young doctors: they are all too aware of their shortcomings and afraid of litigation. They will rather perform too many investigations than too few. And in this case, it was what Mom needed.

She struggled to get a history because Mom was crying. I don’t know how much of it was pain and how much of it was relief at meeting a doctor who didn’t tell her it was all in her head.

It’s five months later and Mom has a diagnosis. It’s not a diagnosis many people believe exists. There are some doctors who believe that FM doesn’t exist. But I look at my mom – an exceptionally strong woman who gave birth without pain medication and refuses to go for stitches when injured – and I simply can’t agree with them.

Mom is on medication now. It mostly keeps her pain under control. She is part of a Fibro trial, where she is receiving remarkable help.

Mom is emotionally better too. She has a physician that cares about more than just her blood pressure. Oh, and her OA is being managed too.

I want to be like that. I know there are many contentious diagnoses out there, but I want not to be blind to that which I do not necessarily understand.

Here’s to the exceptional people struggling with pain every day. I salute you.

Book Review: The Brain That Changes Itself

As a rule, I do not review non-medical books on this blog, unless it forms part of a Top Ten Tuesday. However, since my recent discovery of the myriad of book blogs, Goodreads and the ability to read while maintaining my schedule has led to me rather bravely attempting a bookish challenge, I have decided to blog about those books.

For the category of Science and Natural History I read The Brain that Changes itself by Norman Doidge. Thanks to SolitaryDiner for the recommendation.

In biology we learn that skin heals, bone forms calluses until it is almost as good as new, and half a liver can soon be a whole new liver. But the brain? The brain doesn’t heal. You break your brain and it stays broken. Even more than healing, the brain doesn’t change. Once you’re all grown up, the grey matter you have is the grey matter you are stuck with until that, too, starts to degenerate.

It is exactly these teachings of popular science that Doidge challenges in his book – a scientific work of literature that reads like a novel.

Doidge travels the world to meet with patients, scientists and doctors who have shown that the brain can – and does – change. And not just after injury; it does so constantly.

In The Brain That Changes Itself we read of learning to balance after damaging the vestibular system, about learning to live again after substantial damage due to a cerebrovascular accident. It tells the story of people who learn to literally “grow” out of their Obsessive-Compulsive Disorder and depression. We even meet a young woman who has lived her life with only half a brain – her right hemisphere effectively doing the work that her left hemisphere would have done.

The view of the brain as a machine – fast, efficient, but unchanging – is chiseled down, revealing a malleable brain. A brain that isn’t only formed up to adolescence, but long thereafter.

The Brain that Changes Itself reads easily, has not too much medical jargon and not too many statistics, but I am unsure how much stimulation it would offer to the layperson. Even I, having studied neurosciences (at undergraduate medical level) sometimes felt that the book was slightly above me.

Note that some may be sensitive to the descriptions of animal testing in the book – but it perhaps offers a fairly good view of why animal testing is not all fire and brimstone.

It took me a while to get through the book because it was intellectually taxing and I felt the need to think and research after each chapter. It was well worth it and I wish I had read this during my neurosciences rotation last year. I feel that I will be a better doctor having read this.

“We love being in love not only because it makes us happy but also because it makes it harder for us to be unhappy.”

Norman Doidge, The Brain that Changes Itself

Brain Cut: Fatal Fall?

We are privileged to have weekly tutorials from the only forensic brain pathologist in Africa. He is retiring soon – which is sad, because he is clearly a genius. He also teaches with passion, which seems rare in our field.

Anyway, we had an interesting case during brain cut today.

A 22-year-old man fell. The Professor’s first question was, “And how do 22-year-old’s fall? From ropes, and buildings, and hang gliders.”

He was a little disappointed to hear that our brain fell while being arrested by the police. Even more so when it was said to be an “alleged fall” – seems reminiscent of our country’s Apartheid era, where many inmates died after slipping on a bar of soap.

So anyway, while he was alive, it was determined that he had no skull fractures, but a sub-arachnoid haemorrhage and haemato-hydrocephalus. They then started investigating for a ruptured sacular aneurysm. None was found. The bleeding in all ventricles continued and an external drain was placed.

He started improving, and then quickly deteriorating. CT revealed first a small area of infarction in the temporal lobe. Two days later it had progressed to a large middle cerebral infarct. He died shortly afterward.

So interestingly, our Professor was tutoring us on aneurysms before we started slicing the brain. Then we got to the middle cerebral and anterior communicating arteries and, presto, nothing. No aneurysm. No sign thereof.

The brain was falling apart though. Infarcts are annoying.

More or less what the brain looked like. Image by Dr K. Mason, Iowa State University

For the first time the external appearance of the brain intrigued us. The vessels were extremely engorged. In between them were small, thin venous bleeds. Our Prof says the only time he had ever seen something similar was with viral meningitides. (Good thing the brain had been placed in formalin).

Our Prof seemed a little annoyed still. Partly, most likely, because it became clear that our understanding of neuroanatomy sucked.

Interesting case though. Even more so since we managed to cover a few diagnoses before finding the one of best fit.

Le Document Pour MB.ChB.III

The inspiration for this document came during my second year while studying for an end-of-block test. At the same time, the then-first years were studying for Pathology, aided by “Le Document”. Somewhere in this time period I looked at a fellow second year, threw my hands in the air rather dramatically and exclaimed,

“I wish I had a Le Document for Second Year!”

Le Document pour MB.ChB.II can be found here. It focussed mostly on holistic wellness during a tough theoretical year. Third year is a whole new ballgame, with students finally set wild in the clinical environment. Theory modules are unfortunately still a reality and at my school, third years are haunted by Neurosciences and Musculoskeletal System.

I throughly enjoyed this year and fortunately I had some older friends who had some handy tips. Thus, some advise for new third years:

Do not freak out if you struggle to draw blood. Practice will make perfect. Accept any challenge, but look out for patients with good veins – they will boost your confidence.

Do not freak out if nurses know more than you do – chances are they have been practicing  longer than you have been alive. Respect them: they can either help you a lot, or make life extremely difficult for you.

ARVs are not a joke. Stressing for an HIV-test isn’t either  Never fool around with a contanimated needle or specimen.

OBSTETRICS: wear a mask when delivering a baby, amniotic fluid does not taste very nice. Always remember tbe infection risk. Wear goggles or a visor and an apron too. Note that if a lady comes in crowning it is not always possible. Remember that the mothers do all the work, it is your job to help them. Remember you are working with lives, always. If told to deliver a multipara, check twice with a doctor or matron.

Ask to take a picture of your first baby, you will not regret the memory.

PAEDS: little humans are resilient, but not made of steel. Be sure you know how to do procedures on them – do not attempt to draw blood from a little human with a syringe. Do not perform a procedure in their cot – it is the only safe place they have. For your own emotional well-being, try not to get too attached. And beware the paediatrician - just because they love kids does not mean they love you.

INTERNAL MEDICINE: this rotation is competitive and exhausting. Try to be on your supervisor’s good side. Take initiative. Look interested. Go the extra mile. Wear comfortable shoes. Read up about all cases on your firm, not only those of your own patients. These are good principles anywhere, but especially important in Internal.

Never underestimate the importance of a good history and a basic physical. If you don’t know what to do, start there. Have a method to your investigation, and a structured presentation.

FAMILY MEDICINE: Do not scowl at this rotation, there is a remarkable load you can learn here , especially if you learn to respect the multidisciplinary approach. Be well prepared for site visits, take sturdy shoes and hand- sanitisers. Take the time to understand you patients’ psyche and sociology, there are not many blocks that cater for this.

SURGERY: not my favourite rotation. Apparently doctors fall into one of two groups: those who love surgery and those who despise it. Surgeons can be scary and temperamental, but try to learn as much as possible. Attend tutorials even if it is easy to slip out. Assist in surgeries even if other students are willing to relieve you of your duties. Do not stress about assisting, you will be told what to do. Most importantly, know how to scrub in and practise your suturing.

With so much practical, theory becomes mundane. Do not lose sight of your goal. Attend classes. If you get bored, look for blogs, student sites or books to pique your interest. For example, The Brain that Changes Itself promises to be a great addition to neurosciences. A Life in Pieces is exceptional for psychiatry. Three Letter Plague as well as Disease are gripping. Musculoskeletal system requires great effort. Colour in, draw, use your friends’ anatomy and don’t let the skeleton stay in the closet.

Third year is wonderful and can ignite your passion for medicine once more. However, you must take good care of yourself. Sleep often, eat well.

And don’t forget your stethoscope.

Another Day in the Frontal Lobe

Did I ever tell you that a single book gave me the push I needed to accept my spot at Med School? The book in question was called 28 Stories of AIDS in Africa, but this is not about that book.

In previous years, books were like my daily bread and water. With the workload and activities of university I seem to have been starving for almost three years. I read the odd book, but struggle to find a book that will touch me without instantly sending me into a downward spiral of depression.

During a rare gem of a three week holiday, Ouma and I went on a little excursion to the library. Here’s what I found:

Another Day in the Frontal Lobe by Katrina S. Firlik, non-fiction

Firlik is a Neurosurgeon in the USA. She writes with wit and insight about the road that brought her there: from the decision to be Pre-Med, to Med School, through seven years of residency.

She avoids the various pitfalls of medical biographies:

She does not jump up and down cheering her team on as the one and only.

She does not impress upon the reader that her job is the worst or most difficult.

She does not focus overtly on research or her work in the field.

The writing is unapologetic and honest. As a medical student (albeit in a different country) the autobiography cleared up many doubts in my mind helped me to alter my way of thinking about medicine a little. It was enlightening.

It is also perfectly suitable to the layperson though. I found myself reading entire excerpts to my parents and they thoroughly enjoyed it. When Firlik touches upon medical subject matter, she is sure to make it clear enough for those without a medical background.

I would also strongly suggest Another Day in the Frontal Lobe to anyone who enjoys reading about women making it in the professional world.

A mention must be made that the author impresses her view regarding religion once or twice. She is by no means degrading, but religious readers should be able to read past it and still hold on to the story.

If you have an expanding blood clot in your head, you want a skilled brain mechanic, and preferably a swift one. You don’t care if your surgeon published a paper in Science or Nature.

Firlik, Another Day in the Frontal Lobe

Neurosciences 271: Pretty Darn Cool

Today I feel lazy and not in the mood to study, even though I have a big test next Friday. I felt so lazy that I actually got up and made some Rice Crispie cakes; and then proceeded to eat them all. All in the name of not studying. I feel quite ill, if that is any consolation.

Rice Crispy Treats, image from wix.com

Anyway, in an effort to feel like I have done some revision today, I figured I’d go over the reasons I think Neurosciences are, to use a 90s expression, the bomb.

Not only is the department super organised and put a lot of effort into teaching, but it is also SUPER interesting. That’s a lot from somebody who, for the most part, found second year to be a drag.

Ever bumped your toe and instinctively curled up in a little ball clutching it as though it might fall off? There is a very nice physiological reason for that. In the afferent part of our peripheral nervous system, there are stimulatory neurons and inhibitory neurons. The activation of certain neurons on one little spot of toe can have an inhibitory effect on the neuron in another little spot of the toe. Thus, while pain may be the stimulus, applying pressure in a nearby spot activates an inhibitory neuron, which ACTUALLY lessens the pain.

That sounds way more complicated than it did in my mind and I now cannot find a nice picture for it on Google.

It gets more interesting. Why does it hurt when you touch an open wound? That sounds like a stupid question right, like DUH, it’s an open wound, of course it will hurt. But what about a bruise? Or a torn ligament? We possess over something called wide dynamic range cells. These are specific receptors that only work once activated by pain. In other words, they sense pain only once initially activated by pain. Pain = more pain. In essence, they lower the pain threshold, which is why you are then more sensitive to modalities that may previously not have hurt.

“Seeing stars” is also not just a metaphor. Every sensory receptor in your body is made to register only a specific stimulus. This is called “label line coding” and explains why you can’t hear with your fingers (lip reading doesn’t count). The rods and cones in your retina are only made to register vision, and so any energy applied to it will be interpreted as a visual pattern.

Many of us know that a particular smell can awaken emotions much easier than say, a view or a melody. This is thought to be because the olfactory sense is the only sense that isn’t first routed through a part of the brain called the thalamus. The sense of smell passes directly to the cerebral cortex.

We also do some ophthalmology. A lot, actually, and I find it quite interesting. Quick, tilt your head to the side.

Can you still read this? It doesn’t appear skew?

That’s because of some pretty cool muscles of ocular motility, the superior and inferior obliques. It is their job to keep your eyes gazing level even when your head is tilted.

Also, it seems that the image projected to your brain by your eyes is actually a pretty fuzzy, pixelated and rudimentary image. Our brains fill the missing gaps to create the clear image we see. Now I think – and this is purely a theory and I have NO EVIDENCE WHATSOEVER – that maybe that is the reason we view different things, different people even, as being attractive. Maybe? Maybe because we actually SEE them differently. Just a thought. A pretty clever evolutionary trick if you ask me.

So I think neuro or ophthal are pretty cool. Who knows… it might just be my thing…

Neurosciences 371: The first dissection

South African medical students are very fortunate in that we always have access to cadavers for dissection. Many western countries, as I have been told, simply don’t have these available to medical students.

My class started dissecting in September 2009. The new syllabus is all about integration, so where in the past curricula students spent about a year almost exclusively dissecting, we now have dissection at the beginning of most bodily systems. We have now dissected just about everything except the head/brain/spine and the musculoskeletal system.

Today we started with Neuro-dissection. At this point I should mention that dissection has never really been a problem for me – so much so that that bothered me. I couldn’t equate the body lying on the table with that of a human. It seemed to be only a shell, which I suppose it really is. In my culture, at least.

Cadavers are covered in large sections of cloth, doused in formalin. So while you are dissecting the abdomen, the chest, head and legs remain covered. Firstly this prevents the body from drying out too much (a cadaver is very very valuable and we only have a new intake once a year), but I think it also serves to provide some dignity.

In today’s dissection, we needed to make incisons (to the bone) from the nasion through the bregma right to the opisto cranion. Then another incision from just above the ear, through the bregma to the other ear. We then had to reflect the all the layers of the scalp to bear the skull. I tried finding a nice picture but there were none, so this is an illustration of the different landmarks so you can get an idea of the area of dissection. It is from “Applied Anatomy: the Construction of the Human Body“, by Gwilym G. Davis:

Landmarks of the Skull

This was more difficult than any of the other dissections. Not because of technical difficulty, but because there was no way of denying that our cadaver was once alive. We have just recently had the new intake, so our cadaver is practically untouched, save for the second years who have started their thoracic dissections.

At one point I needed to lift his head for my friend to be able to extend the cut to the occipital protuberance, and as I did my hand rested against his ear. And cold and stiffened as the rest of the body may be, his ear was soft, elastic. It felt akin to what one might feel when caressing the ear of a lover.

On a more positive note, I got to cut a little today. Last year I was, as mentioned before, not very good with class attendance. The times that I was at dissection, I was afraid of making a fool of myself and so I did not demand my fair share of cutting. And nobody is really going to offer it to you if you don’t demand it.

In the world of young medical students, experience is a most prized possession.

I was beginning to worry that I would never know what kind of pressure is necessary to reach bone or viscera. Skin is actually very thin, do you know that? And there is really not that much space between our skulls and the outer layer of skin.

Now, if you’ll excuse me… I need to get rid of this formalin smell.

Neurosciences 371: The Beginning

Today was my second day of class for the year. I have not yet received my results from Friday’s exam – which was horrible, by the way – but I can’t very well not attend classes.

We are doing Neurosciences 371 now. I have not yet learnt terribly much, but I think it will be interesting.

Useless bit of information: A single neuron can be up to one metre long! (Apparently it is usually the one from your big toe to your spinal cord.)

Also – I don’t know if I am the only stupid one who didn’t know this – but a nerve and a neuron are not the same thing.

Nerve: A cordlike structure made up of a collection of fibres that convey impulses between a part of the [CNS] and some other region of the body.

[Dorland’s Illustrated Medical Dictionary, 31^st Edition]

The “collection of fibres” is basically the nerves.

There is also a very good reason why a lack of sunlight may precipitate depression, and it is not as simple as “You don’t have enough Vitamin D.”

Neurons are insulated by myelin sheaths and 80% of their constituents are lipids. For efficient lipid synthesis, we need Vitamin D. So when we don’t have that, neurons are more poorly insulated, giving rise to a myriad of neurological disorders, including depression. I suppose that same fact is the reason a completely fat-free diet is not good.

The rest that I have learnt I still need to revise, as they seem quite complicated. A lot of anatomy, electricity and chemistry. I refuse to have a repeat of last year. Remember how I said I would be a better student? Well, I am going to.

I have been attending classes, but it is a huge struggle to stay awake. I am hoping that if I attend all my classes this week, it will become a habit.

The lecturers we have are rather boring, but our very last hour today was the best. The professor is really funny and rather eccentric. He wore this little black bow tie, and he has this odd silver patch in his hair. He is very lively and might be the reason I end up enjoying this module.

When explaining the different modalities to test for sensation (temperature, pressure, pain, etc) he asked himself why, if sensation is pretty much the same all over (whatever that means, my attention must have drifted), we use so many different modalities? His answer:

Doctors are pretty conservative, they don’t like changing things. You pay a lot of money studying to be a doctor; you don’t really want to hear that what you learnt is rubbish.

My friend says that liking him won’t last very long, especially not once we have had our test and exam. But… one can hope.