The rumors were true

Moving

2006-09-21T13:53:00.001-07:00

I have moved to http://rumorsweretrue.wordpress.com

RSS Feed

I know it's a pain in the ass, and I apologize. The new place has everything I've written since the first day of first year (whereas this site only began in my second year). Things are better categorized and navigable. I like the layout and the ease of use as well.

So, sorry for moving. The Drunk-Driving post will be finised at the new site after my exams this monday.

See you at the new place, topher.

Grand Rounds 2.52

2006-09-19T05:54:00.000-07:00

Grand Rounds is up at Tundra Medicine. Go read the week's best writing from students, nurses, doctors, etc.

Drunk Driving

2006-09-16T00:01:00.000-07:00

I do not care much for scare tactics. It is a right of passage in high school that a local police officer comes before the entire student body to give a lecture on the dangers of drunk driving. I remember hearing about it beforehand that this guy used scare tactics and would show us a bunch of car crashes that claimed the lives of teens 'just like you'. Most of my friends thought, “Cool! I like car wrecks. Let's see who totaled his car the worst.” Slide after slide of cars bent around trees, charred from fires and road scenes cleared of everything except a little blood on the asphalt clicked by. We would snicker to each other, “Wow, that guy must have been going fast.” Sure, we were being callous on purpose, but the consequences just couldn't register anyway. Then he brought out the beer goggles.

These were thick plastic lenses that horribly distorted your vision. He lectured us about the level of alcohol in your system after a single beer, and how you were drunk after just two. Don't believe me? I'll show you what it's like for someone your age after two beers He asked someone to come onto the stage to wear the goggles, and he would let us all laugh at our friend's inability to walk against his best efforts to just ‘maintain’. That’s when the officer would yell sternly, “That’s what it’s like when you’re drunk! Not funny, is it!” What a bag of mixed messages.

Presentation style aside, we didn’t take him seriously because we knew the magician’s trick. We had all been drunk and, from that, we all knew that those goggles were far from our experience. Inebriation after two beers was far from our experience. His mistake was trying to shock and scare us into doing the right thing when giving us the information about alcohol's effects and trusting us to make the right decision might have worked. After all, regardless of what is said in a lecture hall, the decision was going to be ours.

The reason I am relating this: it was not until I was in medical school that I was given all of the information about alcohol that would have been so useful then. Though I long ago recognized the unacceptable risk of driving drunk, it’s only now that my decision feels informed. I do not see why this moment has to come $100,000 later, eight years out of high school. Worse, I recognize that very few people are ever in this position to learn it.

I'm going to try over the next few weeks to lay out everything that I have learned in the past two years that has helped me reconcile my experience with alcohol with the science of alcohol. I want the person interested to understand the greater story of how our body and brain interact with alcohol, why understanding it is exciting in and of itself, and how knowing all of this might help you put your own experiences into a context more helpful than a car crash.

It is my hope that you can make the decision yourself, informed.

***

The brain is divided both in shape and in function. In shape, we are used to thinking of a left brain and a right brain, but the biggest differences are between higher and lower function. The classic picture of the brain is of the mess of infoldings that is split down the middle. This is your cerebral cortex with its left and right hemispheres. The highest of your thoughts live here. Pronouncing a word, telling a joke with the right emphasis, drawing a picture; all of it is happening somewhere inside those folds. Not every spot is created equally: some of the areas in your cortex are incredibly important (being able to speak) while others are less important. For example: Phineas Gage. The most famous survivor of brain damage, Phineas was a railroad worker who accidentally triggered an explosion that sent a railroad spike through his cheek, left eye, and into his brain. The only thing that changed was his personality. James Shreeve writes “[i]n place of the diligent, dependable worker stood a foulmouthed and ill-mannered liar given to extravagant schemes that were never followed through. ‘Gage’, said his friends, ‘was no longer Gage’.” Even so, he was still alive and functioning.

It is hard to understate how incredible an idea this is. There are parts of our brain that, should they go missing, we may never care. There are parts of our brain that when damaged, merely change aspects of our personality. Remove the entire brain and we certainly die. Exactly how much of the brain could be whittled away before we could no longer live? What parts are essential to life and what is going on there?

***

Why do we drink? I am not trying to be philosophical, but I am trying to reduce the urge to what it is: it pleases us. We drink in celebration, to lower inhibitions, to blunt depression, to satisfy addiction. The ways in which alcohol is used and abused are not important for the discussion here, but I do want you to appreciate how powerful a motivator our own pleasure can be.

In the 1950s, two scientists performed a famous experiment on rats. To map the brain (even now in neurosurgery) the physician will electrically stimulate an area and test for the expected response. Imagine a patient awake, with his brain open to the air, as a surgeon electrically disrupts certain areas looking for the portion of the brain that stores “mammals”, for example.

“Okay Jimmy, I want you to name every mammal you can think of.”
“Elephant, dolphin, tiger, ...daaaaaa”
“Got it!”

Today’s neurosurgeon benefits from a rough map of the brain that has been established over years of investigations. But what if you didn’t have even a rough idea? What if you were back in the 1950s? Peter Milner and James Olds decided to poke around.

They experimented by implanting electrodes into the brains of rats, electrocuting them, and watching for the effects. They found that with a certain placement, the rats appeared to experience ecstasy on stimulation. Had they found the rumored “pleasure center”? Next, they introduced a lever into the cage that the rat could press at will to send a stimulus directly to its brain. What they found was disturbing: the rats would press the lever 2,000+ times an HOUR. They rats wanted it more than food and water. They would press it until they died.

***

This post will be completed at my new home, The rumors were true

Six months

2006-09-15T12:01:00.000-07:00

Six months. In six months I will have taken the USMLE step 1. I will go home, pack my bags, and get on a plane. In six months I will be in Southeast Asia.

I will swim with fluorescent algae. I will push my arms through the water and watch as their outline of my arm glows green/blue and then fades. I will get out of the water and watch the drops fall clear and splash brightly against the sand. It will be like cold, liquid fire.

Vietnam, Laos, Thailand, Cambodia. Two months between the USMLE and Clinicals in New York. My backpack, my roommate, and the $4000 I didn't spend on a Kaplan course.

Southeast Asia. Six months.

Can't wait.

Psych 0-5

2006-09-14T16:04:00.000-07:00

Another psychiatry experience today. This man hallucinates fisherman turning into giant frogs. He describes smells coming to attack him. He was jealous of his brother's success so set fire to his mother's house. He tells us all of this while smiling. He says that his sister, who died years ago from GI cancer, visits him in recurring dreams. She keeps trying to have sex with him, he says. He's missing a leg. Really 'missing' it, as in, can't remember where it went. His file says that after setting fire to his mother's house, he attacked his guards in prison and they shot him in the knee. No heroic measures were taken to save the limb.

All of that sounds interesting except I can't focus on any of it. There's a patient in the courtyard outside the window whose been playing the guitar for the last two hours. He's a very good player and singer. I wish I were outside and far away from this guy's problems.

I told my roommates today that I was very close to ruling out psych altogether. They all laughed at that: "Like you could ever be a psychiatrist." I'm not offended by this at all because it's just so completely true.

SHOUT*!

2006-09-13T08:51:00.000-07:00

Every once in a while, I write home to my family.

My landlady just popped and brought the baby over. While my roommates are cooing over how cute he is, I ask if I can hold him. Want to know a cool trick about babies?

If you let a healthy baby's head drop suddenly, it's arms will reflexively extend and grasp. I think this is a defense against falling from the mother's arms. Instead, I like to use it in the following context where "*" means dropping the baby's head.

"Now waiiiit a minute. You know you make me want to SHOUT*! Come on now, SHOUT*! Come on now, SHOUT*! Come on now, SHOUT*!"

By the way, this never gets old.

Greetings from St. Vincent.

Medical school is much different now. The material is coming like a flood, and every second you spend marveling at how much work you have to do you're ending up farther and farther behind. Procrastination, I'm learning, is a luxury I don't have.

Instead of teaching me how the body breaks, they're teaching me how to fix it. I know this is the point of medicine, but I swear to you that over the last 18 months I completely forgot about it. I'm also learning that the body, while split into the parts of heart, lung, liver, etc., is still connected. Say goodbye to the days of easy questions that dealt with just one of these systems and say hello to the ricocheting questions that begin in the stomach, enter the heart and leave the spine. It's all much harder, but in the way that it should be. I'd be disappointed if this ever got any easier.

Alice is ten feet tall and drugs are fascinating. Learning all of their names, side effects, contraindications and uses is like getting the keys to the car when you're sixteen. That you'll crash the car is a given, but dammit if it isn't exciting! What's worse, while I'm getting excited over a few names and a basic understanding, I still have no concept about delivery method, dosing, chronic v acute management, which drugs are more expensive and which drugs have conflicting benefits in the literature. I'm going to be stupid for a long time yet.

The school is REALLY trying to help us look the part for clinicals in New York. To get that newbie shine off of us, we're getting soiled in the local hospital. Everyone goes twice a week to round with physicians and answer questions incorrectly. It's great.

Embarrassed to ask a 60-year-old about her sex life? Newbie shine.
Hesitant to lift a woman's breast to listen to her heart? Hope you don't get any blood on your scrubs? Can't tell a collapsed lung on an xray? Newbie shine.

It's slowly coming off.

Anyway, the work is killing me and I have to disappear for a month. I'll write again when some funny things happen. Oh, other things that happened since I last wrote:

Went to Milwaukee to give a speech. It went well. Went to Michigan for vacation with the family and became more tan than I ever was in the Caribbean. Went to Alabama for research. I got to dissect a fresh cadaver, which was incredible. The 70-foot stained glass window I made was finally installed in my patron's home. I'm very proud of it. My youngest sister took off for College in Colorado. I'm very proud of her.

SHOUT*!

This is what I'm talking about

2006-09-13T08:20:00.000-07:00

The other day I had some sour grapes over my experiences in Psych. My feeling was disappointment over the disconnect between what I read from folks in the field and what I experience clinically. For those that don't get the chance to surf as much, The White Coat Rock has two excellent posts today:

Drugs, Hugs, Hags, and Has-Beens:

"There is nothing lamer than people who live a sort of drug-filled, hedonistic lifestyle, then come to see the light and become crusaders against what they once enjoyed. You find this occassionally, former hippies or scenesters who suddenly find religion and then go around telling everyone 'Yeah, I did this stuff, and really enjoyed it too. But I realize now it was wrong, and you all shouldn't do what I did.' Hey, you had your fun, so keep your fuckin' mouth shut and let others find their own paths.

That is my brand of anarchism: don't let anyone tell you what the limits of your experiences on Earth should be. It's your right to fuck up. Just don't whine so much if you find yourself down and out."

Personality, or Lack Thereof:

"I've been in a pissy mood recently. Inexplicable. Need to remember to leave my knife at home. Can't afford to get into any knife-fights.

Anyway, I've been thinking about personality disorders recently, since we talk about that a lot on the psych wards. I don't like the idea, never have. As far as I can tell, the personality disorders were invented by psychoanalysts who got frustrated by patients they couldn't pin on a discrete diagnosis on, but who had enough indiosyncrasies for the therapist to suspect they 'just weren't right.'"

The Bell Curve

2006-09-12T09:55:00.000-07:00

Those outside of medicine, I want you to know this: doctors are doctors because they know medicine. They are not doctors because they are great teachers. And who teaches future doctors? Doctors do. For students looking to learn, it's the lottery of the bell curve. Will today's doctor also be a great teacher, an ok one, or confusing? Most of us will end up drawing in the middle. This week it feels like I'm on the losing tail.

To the clinical tutors I have had this past week, this is my open letter to you:

If you ask me to take a patient's history, then let me. Do not interrupt me because you think that asking her about her work with the church is irrelevant: I am trying to assess her physical activity and social support. This will of course vary if she simply attends or if she helps in community building activities. Savvy?

Every time you interrupt me, don't kid yourself that it is for my benefit. You have, in your mind, the order of questions that you would ask. I know you think it's the best, but it can't be, because every single tutor has a different order. What you ARE doing is upsetting my rapport and rhythm, confusing both the patient and me. So, if your goal was to teach me, you're steering us into rocks.

When I ask the patient, "So what brings you here today?” they always respond with their chief complaint. Never has one of them responded with "the bus" or "my Dad" or "my legs." Every time you interrupt me to say that I should have asked that question in such a way as to preclude these responses, you are proving to me, beyond doubt, that you are only interested in finding ways to assert yourself. It's like being taught by a smartass fifth grader. Stop it.

If there are two of you overseeing the group, agree beforehand as to which of you will be the leader. When you interrupt and contradict each other, it's bad for both of you. My options here are to assume that one of you doesn't know what he is talking about or that one of you is an egomaniac who has to assert himself. Nice teamwork.

If your goal is to mold students in your own likeness, then lead by example. If you quietly do an amazing job and explain to me why you make certain choices, I might just decide to emulate you. Slinging mud at other doctors and then bragging about being clean does not impress me.

How are these things not blindingly obvious?

When you pimp me, what are your goals? If you want to teach me how to think like a physician, then lead me with your questions in that way. If you want to show me that you know more, then please, continue to ask the same question repeatedly, basking in the six minutes it takes before someone's dart in the dark hits your bullseye.

I feel like I owe you, the reader, an example.

The physician is asking us about the presentation of a complete break in the femur (thighbone) that is displaced (pieces are side by side). We say immediately that the thigh will be shorter (because the broken pieces slide up against each other since the attached muscles are still pulling). However, we were missing something.

"What else would you see?"
"Bruising?"
"What else?"
"Patient is in pain?"
"What else?"
"A bump where the femur is displaced?"
"What else?"

Pretty annoying, right? Doesn't exactly have you thinking like a doctor, does it? Here's my idealized version of the same conversation:

"Why is the thigh shorter after the complete break?"
"Because the attached muscles are still pulling."
"Do those muscles simply pull in one direction?"
"No, sartorius is involved in external rotation."
"So what else would the muscles do to the leg that is broken?"
"Oh, externally rotate it!"
"Correct."

I haven't had that tutor yet. I'm waiting for the law of averages to give me some time on that better part of the bell curve. When I get there, I'm going to try to become a sponge. For now, I'm trying to stay Teflon.

Wasted Mind

2006-09-08T08:16:00.000-07:00

I have no idea if this is normal. Going to school in the Caribbean is great, but it isn't the US, and for that reason I always catch myself wondering if my experience is a "normal" experience comparable to my US studentdoctor peers. Here goes:

I'm still in M2 and the school is interested in giving us a lot of clinical exposure before the clinical years. It's the logic of pre-kindergarten. Twice a week I'm off to the hospital with my roommates to sample Peds, Med, OBGYN, etc. In addition, we have Clinical Skills, a class where we take non-sick volunteers and try to work them up for the Congestive Heart Failure that they don't have. So once a week I'm reporting a 3rd heart sound that I don't hear or a nodular liver in another healthy person at the urging of the tutor and feeling very silly. I am fine with all of this.

I am not fine today. Today, an announcement was made in the morning that there will be no Clinical Skills lecture before we see our patients. Mind you that this is four hours away and there will be no effort made by ANY of the physicians available to give a talk, even briefly, on how to conduct a psychiatric exam and the special challenges therein. Almost forgot: I heard a RUMOR that we were interviewing psych patients today. I'd like to get these sorts of announcements from the school before the day of, maybe posted somewhere, but that doesn't happen with the frequency that logic would dictate.

So with no preparation we enter the room. The psych patients will not arrive for another half hour because they have to take their meds at the hospital before being bused over. What?! I don't consider myself a cruel man, but it's going to be hard evaluating someone for a psychiatric disorder when they're TRANQUALIZED. Can't we leave them unmedicated for a while, loosen the leash and let them explore the space? Don't I need to SEE the problem if I'm going to learn to DIAGNOSE the problem?

"You feel fine? You don't know why you're here? You feel happy?"
"This patient is being treated for schizophrenia with delusions of persecution," says the tutor.
"Well the patient can't seem to remember any of that right now."
"That's because he's medicated." I know, you dolt.

What a waste of my time. I could have played tennis against a brick wall this last hour and at least had pit stains to show for it. And what a missed opportunity! This time the patients actually HAVE the problems that we study. I couldn't have been given a heads-up about this for some time to prepare? I hope such poor execution isn't normal.

***

So much of what I read online is written by folks in Psychiatry. We've all read House of God, some of us have read Mount Misery, and all of it seems fascinating. Who doesn't like leafing through the DSM and thinking of the people in our own lives? The mind is why I loved and studied philosophy. It's why I did well in Neuroanatomy. Hell, I've cut a brain out of someone's skull and held it in my hands. It's exciting that so little of what goes on in the brain is understood because that means there is so much more room for discovery. To hear people talk about the patients they treat, the things they say and the sometimes profound shifts in personality that medication can induce makes me want to abandon my dream of surgery and dive right in. I'll admit that, as someone who likes to write, the laziness of just reporting the absurd that someone else invents is attractive.

Instead, it's like hearing about the greatest tasting strawberry icecream and not having a tongue to taste it.

I won't do something stupid and level judgment against a discipline because of a few patients but I will say that, so far, I have not liked psychiatry one bit. I don't have the patience. I don't like staring at a talking rubicks cube, trying to figure out the right moves to let some bit of truth slip out. I don't like feeling that I have to trick a patient into contradicting himself to help him understand something. I cannot stand the repetition. I don't like seeing people tranquilized, or talking to people with no memory, or watching someone fidget and pick at herself uncontrollably. I know that these people need the help to beat those problems; I just don't think I want to be there for any part of that journey. I'd rather just read about the successes.

I hope it gets much much better. I'm afraid that it won't. Any words of (dis)encouragement would be welcome.

Silverback, MD

2006-08-31T15:38:00.000-07:00

Tevin is a neat kid, maybe 12, whose mother slams his head into walls until he stops asking why she's beating him. He likes the disappearing-thumb trick that my father taught me. Mrs. K has just had her foot amputated because of uncontrolled diabetes. She doesn't understand any of this, knowing only that she has "the sugar". Jeremy has "THUG LIFE" tatooed across his chest and an icepick in his left shoulder.

It's a jungle in here.

We're finally in the hospital. Imagine us, each wearing our Grownup clothes under bright white coats, stethescope-necklaced with pens and books stuffing our little pockets. We look pretty stupid. For a lot of students, this is their first patient exposure. You can imagine the shock of all of this. Imagine how they balk at having to pull back the blankets from an 80-year-old woman and lift her sagging breast to listen to her heart sounds. Imagine their stuttering steps, their over-explainations to a patient who could not care less, and their unease with the breast-chalk that now tarnishes their previously shining virgin stethescopes. It's pretty great, actually. Really brings me back...

My first patient was a 90-year-old. She was lying, her back to me, facing her daughters. I was a few steps in the door when she said with some excitement, "I smell a man!" I did not know how to act just then, having no precedent. My last patient was Mr. H. We had a conversation about his plan to die at home and how he was preparing his children for that day (which was a month later I heard). It doesn't take long for people to break through the awkwardness of taking a sexual history or talking frankly about death. It's this amazing privilage that we have as medical professionals and I'm so EXCITED to watch my friends and classmates go through the whole thing over the next two years.

Of course, I still know nothing about how to provide care. None of us does. It's disorienting to know so little after studying so much and it's the doctor's job to make sure I stay aware of it. I'm told that in the jungles of Africa, when a Silverback gorilla spots you, they will scream and charge. If you run away, it will kill you. Instead, curl into a ball and break eye contact. The Ape will stand over you, snort, and then leave having established dominance. From then on, you're free to walk amongst the trees.

So I'm standing in a jungle of knowing nothing when along comes Silverback, MD. Jeremy's icepick had come close to this brachial plexus* so the doctor started to ask questions, slapping me around with his paws. I made the mistake of answering correctly, which is like eye-contact to them. He batted me harder, asking about all sorts of random things to throw me off any balance I pretended to have until I fell, incorrect. "Look at how small you are in my jungle! Look at it!" he was screaming, while beating his chest and snorting. Patient after patient, he kept poking at me, waiting for me to look up. Playing dead was useless: the poking would continue until I answered and the beating would continue until I was wrong. In case you were wondering, I'm pretty sure this is how they train students.

Doctors are like Silverbacks with amnesia and I've got to find this one a kitten or something to bat around so he'll stop playing with me.

If anyone needs me, I'll be in the fetal position.

*The brachial plexus is a large jumble of nerves around where your neck meets your arm and it contains every nerve to control your arm and sense the covering skin. It's what a bouncer grabs to cause crippling pain. It's where actors get shot without consequence. This is why actors can walk past bouncers unharmed.

Grenadian Weather

2006-08-29T10:02:00.001-07:00

The wet season is very wet and runs from August to December. It can rain for days on end. If you bring an umbrella, make sure it is the type that opens to form a complete sphere around you, because the rain falls sideways. Honestly, go to a camping store and get a waterproof cover for your backpack, a light waterproof jacket and a shamie. You will be the envy of everyone. Another thing to consider is the mosquitoes. The breeding ground for mosquitoes is standing water, and there will be a lot of it. Invest in a mesh tent for your bed and screens for your windows (only applicable if living off campus). Want to know a fun trick? Instead of a mesh net, get a standing oscillating fan. If you go to sleep with it by your head, the mosquitos get sucked into the back of it and murdered. You get to wake up the next morning with a pile of them on the ground. Good times.

There is little rain in the dry season which runs from January till June. It is the best time to be on the island and enjoy everything that it has to offer. Go to the beach, learn to kite surf, bring your surf board, or rent a jet ski. Head to the capital and learn how to haggle in the market. Most of all, remember to get a tan so that people believe you when you say that you go to school on a tropical island.

Island Culture

2006-08-29T10:02:00.000-07:00

English is the language spoken in Grenada. In the school guide, they describe it as a “slightly lilting Caribbean accent”. I disagree. Those Grenadians that work with the university, or in another position that requires constant exposure to tourists and students, are easy to understand. Those that have very little exposure to foreigners can be near unintelligible, but once you have an idea for what someone is trying to say, everything seems much clearer. It is not unlike listening to lyrics from a difficult song after you have already read them in the CD jacket.

If you have a healthy sense of humor, the stressful things about Grenada can be hilarious. First off, if you go to a restaurant and read the menu, do not kid yourself and think that what is on the menu is available. The menu is instead a list of things that were once available and may be available in the future. This is due either to a lack of ingredients, the staff is too busy to make your order, or the staff does not care to make your order. So order something else with a smile.

Second, if you order a drink at a US bar and it takes more than a few moments, it is often because the place is very busy and the bar is understaffed. If you order a drink in a Grenadian bar on a dead night when you are the only customer, it will take even longer. This is not because the bartender is trying to piss you off or ruin your whole day as some dramatics will say, it is instead because the island is a slow place and you need to get used to it. That Grenadian bartender could turn to you and ask, “What’s your hurry anyway?” Try to remember that there is no hurry and life will be a lot easier on you.

School Culture

2006-08-29T10:01:00.001-07:00

During your first two weeks here you have carte blanche to introduce yourself to as many people as you wish. Your class will probably go out each night that first week and I recommend you go each time. The first week does not contain difficult material and you will not have another chance like it. After this grace period the classes pick up a bit, people fall into routines and your opportunities to meet every member of your class will start to drop off.

SGU operates by four-month-long terms. This tricks you into thinking that each term is a year long and that people in second, third and fourth term are somehow separated from you. This is of course nonsense. The uppertermers will have advice for you on every class and most of it should be ignored. Instead, find a good DES tutor, give yourself a few weeks, and then start making judgments on how to handle your course load. Everyone should go to the Department of Educational Services (DES) office and take a look at all of their handouts on studying, test-taking strategies, and review sessions. It is a goldmine of helpful information.

SGU students study like they party: hard. Go to the Crab Races at The Owl every Monday night at Grand Anse beach. On Wednesday, everyone heads over to Stewart’s Dock for drinks and a live band. If you like to keep going until 4am, Banana’s is the place for you. There are so many organizations on school that every weekend has at least one sponsored party at the Aquarium, Thai Beach, Kudos, etc. Take advantage while you can. Before too long you will start looking forward to the weekend because it means no more classes and you have time to study. Yes, you will be ‘that guy.’

The Day-to-Day

2006-08-29T10:01:00.000-07:00

As a First-termer, I got up every morning around 7am and checked the class schedule. Typically only two courses are taught a day with each getting two hours of lecture time. On some days you will have Anatomy lab that can begin at 8 or 9am and lasts for three hours, or you have Histology lab at 8 or 10am that lasts for two hours. Lectures begin at 1pm each day and last until 5pm. You do not need to bring much to campus. I usually put my laptop, water bottle, two three ring binders and two textbooks into my backpack and grab the bus.

Eating on campus is not hard though students do complain about the selection. At the top of the hill (you will know it well) there are vendors selling fresh fruits and the Patels selling homemade Indian food. Halfway down campus is the Student’s Center which has two restaurants (Glover’s and Pearl’s) along with a convenience store. At the base of campus is the Sugar Shack. You will not go hungry.

Time before and after lecture is often spent in the library. The library has wireless internet and so should your computer (the “Computing at SGU” section of the SGU website does a good job of preparing you). During peak hours it can be difficult to get a strong connection (bringing an Ethernet cable is a bad move, as many of the plugs on campus work sporadically). The wireless network extends throughout campus into the lecture halls (you can follow lectures online or check email during breaks), across to the bus stop and down to the Student Area (where the gym and restaurants are located). Some students are able to get a connection in their rooms as well. If you live off campus in Grand Anse dorms there is a study room with a wireless connection. High-speed internet is available in off-campus apartments through a contract with Cable & Wireless.

The Last Phone You'll Every Buy

2006-08-29T09:57:00.000-07:00

No one gets a landline and you should not bring a cordless phone with you. So that means you are buying a cell phone. Since you are now going to travel from the mainland to Grenada and St. Vincent's (and possibly Prague) you probably want a phone that can work in all areas. For this, you need to buy a Quad-Band GSM phone. There are two main companies that offer GSM service in the USA. AT&T and Cingular are now merged into one company, and the second company is T-Mobile. So here's what you do:

1) buy a Quad-Band GSM phone from one of these companies
2) make sure that it is a pay-as-you-go phone with a SIM card
3) Google “unlock SIM” and pay for your phone to be unlocked

I'll explain all of that:

There are four major broadcasting systems used throughout the world. So a Quad-Band phone means that you'll never have to buy a new phone for travel. The SIM card is a chip that contains your phone number and your contacts. Put another way, it does not matter from what phone you call: if you put your SIM card in any phone the person you are calling will see that it is you. So if you buy a SIM Quad-Band phone at home, you will have a SIM card with your home's area code. When you come to Grenada, you will buy another SIM card with a Grenadian number. At this point, you can simply switch the SIM cards while you're one the islands and then switch them back when you return home. Taping them into your passport is a nice way to keep track of them when not in use.

The reason you have to "unlock" your phone is so that your T-Mobile phone (for example) will operate with a Digicel SIM card from Grenada (for example). Pay-as-you-go means that if you want to talk for ten minutes, you buy ten minutes. If you talk over that, the phone simply cuts off (after a warning of course). This means that you cannot possibly suffer overage charges and you don't get roped into a contract. And why do you have to pay to unlock your phone? Because T-mobile doesn't want you to buy there phone and then use it with an AT&T SIM card. T-mobile wants your money. Typically, these companies will unlock your phone for free if you've owned it for three months, but if you're reading this now that's a bit of late notice. So pay to have it unlocked from a separate code vendor and you should be set.
Some students make use of internet phones as well.

All in All, I paid $95 (phone $50, SIM $20, Unlock $25)

There are several programs that allow you to make phone calls over the internet for pennies a minute to anywhere in the world. Skype, Netphone, and PCPhone are popular programs and only require a headset with microphone.

A Picture is Worth...

2006-08-29T09:56:00.000-07:00

1000 Words

It's amazing how a few photographs taken by students can add some perspective to the place. Go to Flickr.com and search for ‘SGU.’ It says something that the students love the school enough to put all of this together themselves.

My favortite albums are shot by
Josh http://www3.flickr.com/photos/joshy55013
Felix http://www2.flickr.com/photos/sravishankar

Where to Live

2006-08-28T08:19:00.000-07:00

Unless you arrive very early, it is difficult to find a place to live off of campus. You will not know which areas are safe, what prices are fair, and everyone that is coming to the island after First term has snatched up the best apartments. You will probably end up at the True Blue Campus or at Grand Anse.

The University is on the True Blue Campus. There are a number of dorms their: Superdorm #1, #2, #3, and #4. There is also upper-term housing in singles, doubles, four- and six-person suites. Your room will be very small, very cozy. It will also be very expensive. The pros to living on campus include waking up later, not having to use the bus as often, good security and being around people every hour of the day. The cons are the price, the size, campus burnout and being around people every hour of the day. It comes down to your personality.

If you grew up in the projects, you will love the dorms in Grand Anse. You will come home to crabs and lizards. Your plumbing may throw fits and your carpet may begin to smell. If you have ever been camping and like it, then this is the place for you. The pros of living in Grand Anse are the price (considerably cheaper), the location (it is on the beach and across from the Spiceland supermarket and mall), the atmosphere (people that can live happily in those conditions are generally relaxed), the food (Mr. Green Jeans and the Ladies are there to cook for you every day) and the quiet.

When it comes time to find another place to live, you can either enter the Lottery on campus or look elsewhere. I suggest moving off campus. You will be farther away so may need to rent a car and your security is window bars instead of guards, but even taking that into account it can be cheaper and nicer. You can find available apartments through word of mouth or the campus housing office, though their lists are often out of date. You can live in True Blue and this tends to be expensive for what you are getting. The advantage is being within walking distance of campus. The advantage to living in Grand Anse is being in walking distance to every store you could need. Next to Grand Anse is Mont Toute, also a thriving area with several shops. Lance Aux Epines is the Manhattan of Grenada with its paved roads and beautiful homes. Housing can be expensive here, but not as expensive as campus and you get what you pay for.

Arriving in GND

2006-08-28T06:37:00.000-07:00

It is GrenEHda, not GrenAHda. Pronouncing it correctly is a big deal. Grenada was described to me as a third world country before I came and this will not be your experience. Your time on campus will be indistinguishable from any university in the US; your dorm life will be no different than your undergraduate experience. Everyone uses the bus or drives a car. You will have your Subway, your TCBY Treats, movie theaters, malls, grocery stores, hardware stores, school supplies, bars and clubs. You probably will not be able to find the laundry detergent you like or fresh milk, but these are small things. Anyone who says you will be "roughing it" is lying to you.

***That being said, a few people each year have a hard time adjusting. Some have dietary concerns (it is not hard to be a vegetarian; it is hard to be a vegan). Some get very homesick or cannot adjust to Grenada's culture. The pace here is very slow. ***

The very first mistake people make when traveling to Grenada is NOT taking a layover. Often times the airlines will overbook a connecting flight from Puerto Rico to Grenada and ask that passengers volunteer to take a later flight, often the next day. TAKE IT! You will be put up in a hotel, given miles for a flight in the future, and have a chance to enjoy another island carefree.

If you are flying to Grenada on a connection from Puerto Rico you will probably spend your first night without all of your luggage. The reason is simple: you came to San Juan on a very big plane and left Puerto Rico on a tiny little plane with propellers. This is the type of plane where they ask the passengers to move to different seats to balance the weight (if that sentence makes you nervous, self-medicate before takeoff). A puddle-jumper like this cannot possibly hold everyone’s luggage in one flight, so expect at least one piece to be a day late. Make sure that you have some toiletries and two changes of clothes in the luggage that never leaves your sight.
The airline will give you a number to call and you will have your luggage shortly. Try to come to the island early so you can take full advantage of Orientation week. It is nice to have that time for settling in, to speak nothing of all of the trips around the island that are provided.

Grenada’s weather has two settings: downpour and blindingly sunny, so come to the island wearing a rain jacket over a bathing suit. Grenada is likely hotter than you are used to. During those first few days, you will break a sweat from standing, lose weight, and drink water like breathing air. You will see students going to class wearing jeans and long sleeved shirts and wonder what is wrong with them. Just know that your body is getting used to the island; it takes about a month.

What to Pack

2006-08-28T06:28:00.000-07:00

I will only brush my teeth with Arm & Hammer toothpaste. I cannot stand anything else. So every time I fly down to the islands, I have all the toothpaste I’ll need for the term. A girl I knew would bring Downy drier sheets. The point is this: the shopping malls and grocery stores are sparkling clean and air-conditioned much like home but that does not mean that they are stocked the same. They will have everything you can think of needing but not necessarily your favorite brand. So if you are wedded to a certain brand of tampons or deodorant, bring enough for the term. Other than that, there is no need to worry. To the guy that brings 40 lbs. of Whey protein on the flight: we have a GNC-type store that has that. Do no waste the room and the weight. Also, you look like you work out.

You will wear shorts, shirts and flip-flops every day. Have something nice to wear if you plan on asking someone on a date or celebrating at one of the fine restaurants. Every once in a while, their will be a banquet at the Governor’s Mansion or physicians visiting from our clinical years, so have something nice to wear for those fancy people. You will never be asked to wear a jacket, but maybe a tie. Bring a few pairs of scrubs for Anatomy Lab (you can still wear sandals). We have a nice air-conditioned gym, basketball courts and a soccer (football) field so bring some athletic gear and your ‘A’ game. Things made of linen are always a smart purchase.

Binders are expensive on the island and worth the space in your luggage to bring a few. Multicolored highlighters are invaluable when reading biochemistry and hard to find on the island. I wish I had brought more. I also wish I had brought dry erase markers for the study rooms in the library. Bring a flash drive and a modest external hard drive. Students share all of their files and useful programs with each other via flash drives or iPods. That means entire seasons of Nip/Tuck, Lost, 24, etc. Each term also has a MacDaddy program filled with old study resources like previous tests, tables, and summaries. These information juggernauts can reach 10 gigabytes; plan accordingly.

As for your course books, the school supplies you with them the first week you are here. They are stored at the base of campus and are heavy. I would recommend picking them up in an empty piece of wheeled-luggage. Opinion varies in the upper terms as to which textbooks are useful and which never left their shrink wrap. Take advantage of your Footsteps Buddy and try to figure out which books will be most helpful for you. That said, there are some books that most people wish they had. Unfortunately, the campus bookstore may not carry them or will sell out early. Check each Class Section for suggested books.

Depending on your airline, you can take up to 155lbs to the island. That’s two suitcases at 50lbs each and a 40lb carry-on. You’re also allowed a personal item that can weigh up to 15lbs. I suggest putting your computer and books into your backpack as a “personal item.” That easily covers 30lbs, freeing up more weight for your checked luggage. Play it cool, though. If they see you slumping under the weight, they’ll get suspicious and make you check the bag which will cost you some money.

Why go to Medical School: La Soufriere

2006-08-25T05:44:00.000-07:00

I am five years old and running, my arms out by my sides like a banking airplane, around the lip of La Soufriere, St. Vincent's volcano. We're 3,800 ft above sea level and too close to the edge. I have to throw three stones before one goes far enough to hit the bottom of the crater. 10 seconds. That's how long you'd fall and tumble it you made a wrong move. It's easier than you'd think since I'm inside a cloud right now and can't see in any direction.

I wanted to be first. The hike is in three stages with 40ft bamboo reeds bending overhead and hundred-foot drops on either side. We walk into and out of clouds, past rivers of bubble-rock from the previous lava flows, and up loose stones and ash as the summit comes in sight and the pitch increases. We've kept together for the most part, but with the end so close it's each man to his ability. I'm in the middle of the pack and decide to start running. My legs are burning and I'm blowing off huge volumes of CO2. I know I'm among my people when Alexander asks, "Where'd you get the extra ATP?" I start using my hands; it's that steep. I've passed 60 yards at 20 degrees and have the lead by a yard or two. No one else wants to pass me as much as I want to be in front, so it's just a matter of pacing now. But screw it: I start to run again. My legs are shaking and burning and I would feel miserable if it didn't feel great. I summit and it's flat and I start sprinting to the lip.

As a kid I remember being awed by heights. Standing at an edge where a fall meant death, I would let me toes hang over just to know that I could. I was trying to prove to myself that I wasn't afraid. Still am. I sat on the lip with my bag and swung my legs over to lean forward and look straight down. It's never stopped being exhilirating.

Over the lip you can see a massive mound in the crater. It looks like someone tried to plug the volcano. 20 years ago, it wasn't there, but the constant pressure of gas underneath has caused it to bubble out and displace the lake that used to be. Along the side, even 100 meters up, you can smell the sulfur and feel the heat from the center. I'm told that there's a rope that leads down from the lip. I'm too tired today, but next week I'll give it a try.

I am so glad that I go to school in the Caribbean.

Why go to Medical School? We're both crazy.

2006-08-22T08:56:00.000-07:00

Walking out the doors of the Anatomy Lab a man is standing in front of me. His hands are busy around his waste, shuffling his penis back into his pants, smoothing the creases of his underwear and now pulling his pants up from his thighs. He's looking at me like we're both crazy.

"Yes?" was all I could offer, waiting for the punch-line.
"This wear de keep de bodies?" he asked.
"Say that again?"
"The dead bodies in there?" I'm racing through the reasons that he would ask this and why I would answer him. That's when I see the name tag. This man is one of our volunteer patients at the Clinical Skills Lab. Since we don't do genital exams this term I still can't explain why he was undressed and half-across campus, but this is Grenada and I'll have to let all of that slide. He's probably harmless.
"Yes, this is where we keep the cadavers. Can I help you?" Turns out that he came over to find out how he could donate his body to the school once he died. His pants fall down again as I usher him into the Secretary's office. I watch her eye's bug and offer no explanation; I wouldn't want to ruin it for her.
* * *
Going to school in the Caribbean is fantastic if you've got the right head on your shoulders. If you go to a restaurant and read the menu, you can't kid yourself and think that what is on the menu is available. The menu is instead a list of things that were once available and may be available in the future. This is due either to a lack of ingredients, the staff is too busy to make your order, or the staff does not care to make your order. If you need a blown tire fixed, you can open up the Grenadian yellow pages (which might as well say, "no we don't do that, call this guy" on every page) or you can go to the roundabout by Lance Aux Epines and look for a guy with a grey beard and a sock on his head named "Vincent." Vincent, you are told, is a good guy.

Not everyone that comes to Saint George's University can take all of this. Sure it seems like a series of little things, but that's what death by a thousand cuts is all about. I can't imagine what it would be like working in any medical setting (or other high pressure situation) with the girl that stomps her feet when her luggage doesn't arrive on time or the guy that loses his mind whenever we have a Grenadian Traffic Jam.* It's nice knowing that in my future professional life, seeing "SGU" on a resume will mean that they couldn't have made it through while holding on to those attitudes.

The person that does come here, takes everything in stride, and thrives is just the type of person I want by my side if things fall apart.

*Grenadian Traffic Jam: In Grenada, people often stop their cars in the middle of a two lane road to open the trunk and begin selling lemonade. Drivers then weave by to stop, chat and buy a drink. You're going to be late, wherever you were going. Honking doesn't help.

Foreign warning

2006-08-20T11:25:00.000-07:00

I don't write about this but it is an important thing to remember whenever you are going to medical school. Whether it is more common in the US or abroad, I can't know. Mexican Medical Student reminds me:

"Folks, regardless of medical school, there are those who shouldn’t try to become physicians–this path isn’t for everyone. A warning to those American students struggling to get into US programs considering a foreign medical school: a foreign school *is* a viable alternative, but since you aren’t dealing with the “cream of the crop,” (witness the profound statements above), expect to deal with a lot of behaviors from people that you’d think you would have left behind in high school. Add to that, the culture clash of the country in which you go to school, and it’s can make for a stressful mix–all of which, unfortunately, detracts from studying and applying yourself to your task at hand. Be prepared."

Severed Vacation

2006-08-17T09:36:00.000-07:00

I do not enjoy vacation. Studying medicine makes me feel so useful that I go into withdrawal. Reading Atlas Shrugged with all my spare time doesn't help matters any. I try everything I can. I cut my vacation short by starting a week late, electing to stay in Grenada to dissect cadavers for research. I cut another week by going to Milwaukee for the Annual Congress of Clinical Anatomists. I lost a week to a Michigan trip with my family, and I left that early to spend a week at the University of Alabama at Birmingham (UAB). Why? To dissect for research, of course.

My first time in the South and it's everything with fresh eyes. Southerners chew gum lazily. Without wind, you're under a heavy hot blanket. Walking for coffee in scrubs, everyone says, "Good morning, Doctor." It's pleasant.

I was at the UAB with other members of my group to finish projects between the classes of their first year students. We had complete access to 35 bodies and we all felt like kids in the dead people store. Each of us had come a long way from those first heady days of Anatomy Lab. After all, we had chosen to be here without threat of a grade.

We're cutting into people? I don't want to; I'll just watch. I'm glad they put bags over their heads. Should we name her? That's disrespectful! No it's not. I'm naming her 'mittens'. Should we say a prayer first? Oh, god. Give me the goddamn scalpel, Amen. How's that?

For all the posturing, it was a special thing to watch my hand cut into someone for the first time. It was my hand that did it, by the way. I had nothing to do with it. After so many bodies, it losses its specialness. When it's time to work, you approach, address the body, and then dive in for cleaning and measurement. A few minutes later you zip up your work and it's time for the next one.

Most of us have been the ones quick through the door when it came to cutting, the ones that call for the scalpels. But here at UAB, it was a little different. Their cadavers where fresher, fixed with less formalin, smelling less, more robust. It felt like walking into a house so clean that you kick of your shoes even though that's never been your custom.

Most of the students that flew down could give a few days or a week. We would have stayed longer but our classes were starting. Still, some of us decided to start our classes late, this being such a great opportunity for work. Two days before my flight and I make my morning call,

"Marios, what am I dissecting this morning?"
"Severed head."
Choking, "What was that?"
"Ask Vince to show you the severed head. Skeletonize the Facial nerve and clean away all fat and fascia." Hearing my held breath, "Tophy, you okay?"
"Fine Marios. Just fine."
"Congratulations. It'll be fun. You'll do fine."

I find Vince. He takes me into the cooler where they keep the fresh cadavers. These people died a few days ago or a few weeks ago and have donated their bodies to the university. At UAB, there is abundance. I wheel a small bin into the prosection room and remove the lid. Thomas is staring straight at me.

I reach down to pick him up and can't at first. Not expecting the extra weight, I give my arms a moment to recruit more fibers before he moves. It feels like descending the stairs in the dark and going one step into the ground. I hold him in the air while another student helps me clamp the vise grips into either side of his head. Of ~~his~~ head. I adjust the lights, pull up a stool, and grab my scalpel.

I can't do it.

I push his cheek and it moves. I try to draw the backhand of the blade against his scalp to mark my incision and I scratch some of his skin off. Before, I thought that cutting a fixed cadaver was the great big leap, and I was wrong. I stare at Thomas some more. If you're going to be a surgeon, you have to do this. How many people get to work on a fresh cadaver? What opportunity are you wasting?! Do it, topher. DO IT!

I let the blade sink in and I begin to draw the curve of his hairline down to the front of his ear, then drop to the bend of his jaw and forward to the point of his chin. I pull the line upwards and around the mouth, into the sweep of his cheek where tears would have slid and then around his socket and up, until I meet again at the widow's peak. He's bleeding, not in force, but in an ooze that marks each position of a superficial vessel. It's creeping me out.

---------

His face flap is in the bucket. It took an hour to do, pulling up a corner and separating it from all the anchors of fascia. The beauty of dissecting is that you're only as fast as your mind. I was trying to save every vessel and nerve fiber early on, terrified of doing harm, until I remembered that the Facial nerve has no cutaneous branches. At that point it became snip, snip. Finding the target nerves leaving the parotid gland was magic. Pulling against the fat to see all of the brilliant colors of muscle, nerve, artery and vein is something that my fixed cadavers could never do for me. I'm no longer bothered by how real this all is; I'm too busy being hypnotized. The nerves branch and split, branch and split until they are thinner than hairs and I can't believe that I haven't destroyed them yet. They're so strong and wet and alive.

Gross, messy, scary, morbid.

Say what you want about dissecting the face of a man that died days ago. Just don't leave these out:

Amazing, glistening, beautiful, perfect.

Cracked lips

2006-08-12T23:39:00.000-07:00

If someone were to ask me, "What's the stupidest thing you've ever done?", I'd answer with this: trying to be in control.

Working on the terminal onc ward is pretty stressful if you're emotive. People came to our floor because they were going to die. A lot of them were there for a week to receive the next chemo cycle before heading back home. Some of them stayed for longer, months even. But no one ever got so healthy that they left for good. Thankfully, I'm not as emotive as most.

You start to get a feel (or think that you do) for how people are doing. Some are feeling so well that they start thinking their cancer may be going away. Others are holding steady with their treatments, walking up the down-escalator. Some are doing horribly but are stably horrible. Those are the ones that are just agonizing to serve. I remember starting on the floor and taking care of the same women for three months. Every two hours, adjust position in bed. Clean as necessary. It was always necessary.

I remember a frail patient of mine that was in her seventies. Her family knew that things were worsening and that this weekend would be her last. Everyone from out of town was coming in and spending the full day with her. As a tech, it was always a strange experience entering the room to take vitals or perform a blood sugar test. The family members would watch me so intently and then each advance their chins to me, awaiting the result. "Her blood sugar is 136." When there is no control, there must be control. Keeping track of BP, HR, and sugar are all our best attempts at control of some kind.

The family left for the night. I had ten patients for my census and checked in on her as much as possible. She was heading downhill and her breathing was becoming more and more labored until she started using her accessory muscles to pull in the air. They call this "agonal breathing" which just about hits it on the nose. I stood by her side and waited for the nurse to respond to my page. I didn't see her do it, but the woman reached out and grabbed my wrist. It was unexpected and cold and it gave me a start. I reflexively pulled away and then felt a heavy embarrassment and sadness for her. I think I reached out to hold her hand. The nurse came in and the two made eye contact. She had such fear and the nurse looked at her and said that it was okay. You're dying. It wasn't cruel or improper, but somehow perfect for that moment. She relaxed.

There was nothing I could do for her. She was dying in front of me and I would be there for her final new and final final experience. I saw that her lips were cracked. I got some lip balm, held it out, and between gasping breaths she pursed her lips so that I could apply it. That was my stupid attempt at control. I can't remember if I held her shoulder, or hand, or just stood there doing none of those things. She was staring straight ahead, bracing. And then she stopped.

We called the family. They came up the elevators crying at 4 in the morning. They stayed with her until 6 and, before my shift ended at 7:30, I walked into the room. After taking off her gown, I tied her feet together. I tied her wrists together. And just as I had turned her side to side so many times before, I managed her into the big white plastic bag. I wrote her name on a tag and looped it into the zipper. Security came and wheeled her away.

Alive, I could do something for this woman. Dead, I could do something for this woman. But dying? They didn't cover that in training and it seems like something impossible to get entirely right. Even so, when the best you can do is stand in the room and treat cracked lips, it seems especially futile. A new patient with a new cancer and a new family was in the room within the hour.

Two years later and I still feel the pang of failing her that day with my stupid attempt at control. Worse, I know that it was one of her last memories.

Connections

2006-08-12T22:49:00.000-07:00

The way that I came to St. George's University in Grenada is funny to me.

My father enjoys playing frisbee golf. Chances are, you've never heard of it. Each player walks around with a backpack filled with different types of frisbees: long and short drivers, mid-range, putters, rollers, frisbees that cut an "S" in the air, and so on. They throw these things around trees and through clearings toward a metal basket and they LOVE their sport.

My father is a friendly guy with a laugh that makes others want to laugh. He makes easy friends. The summer after graduating from college I was wallowing at a part-time job, hoping for anything medical that could help me gain an apartment of my own. I watched the Graduate and thought about going into plastics. Friendly guy that he is, my father met a nurse named Rob N. that figured the apple couldn't have fallen to far from the tree. He arranged an interview at Big Hospital and I had my job as a tech.

I did all sorts of things at this job and learned that the worst of what I had to do didn't bother me that much. This was supposed to be the litmus test of medicine, akin to seeing a girl without makeup, hungover, vomiting. Still love her? Then go marry her. In my mind, I was ready to go to medical school.

I applied to several schools, was interviewed, wait-listed and rejected. It was from the physicians that I had come to know on the hospital floors that I learned of SGU in the Caribbean. I did some research, was impressed with their board pass rates and residency placements, and decided to apply. A month later I was interviewing and received the first acceptance letter in a long time.

Down in hurricane-wrecked Grenada began the baptism of fire that is Biochem, Anatomy, Histology, Embryology and Clinical Skills in the space of 4 months. I loved it. Socially, academically, and melanin-wise I was thriving.

The next term I had the brilliant idea that I would tutor Anatomy and Biochem. I discovered that in the captive and competitive audience that is a medical class, women find brains as attractive as anything else, giving rise to the phenomenon known as "nerd hot." To boot, my best friend was the most sought after guy on campus. I invited him to tutor with me.

During the meeting of the Anatomy tutors, a knew professor was introduced to us. Stolen from a nearby school, Dr. Loukas said that he was interested in anatomical research and would like to start a research group at SGU. He had our full attention. Meetings were arranged and a club was formed. We were the founding executives.

One year later, our research has continued with few pauses. We put together our projects and headed for Milwaukee for the Annual Congress of Clinical Anatomists to present. I gave my first terrifying speech. Their, we met another professor interested in anatomical research that Dr. Loukas had come to know quite well.

Two weeks later, at the end of what remains of our summer vacation, we are in Birmingham, Alabama dissecting 8-10 projects in 35 cadavers. We begin dissecting each day at 7am and work till 12:30 when the M1's come in to learn about the brachial plexus. We're off till 3pm but can't go many places with the stink of formalin that we wear like capes. Instead we nap and read. I finish The Tipping Point and start to wonder at all the forks in the road that have brought me here.

I fly home. Tomorrow I fly off to the Caribbean to finish the last part of my second year. Tonight, funny enough, is the going away party for the guy that started it all. Rob N. It's the only day I could have been home to see him and say thanks and the last time I'll see him for a while.

Funny though, that it all happened at all.

My First Speech

2006-07-16T10:49:00.000-07:00

Preparing for my oral presentation was awful. I've never spoken in front of a large crowd, let alone a crowd of MD's and PhD's that specialize in the area that my little research project concerns. I'm going to get up on stage, my voice will crack, my hands will shake, I will flub one of my pre-recorded sentences and the pin will skip. I will sweat halos around my arms and neck and then take the audience along the agonizing journey that is reading straight from the PowerPoint as they also read along with the PowerPoint. "Thank you for your time. Please no questions?"

Arriving at the Hotel, I slowly bump into the other 20 students from SGU. We each have practiced our poster presentations to our unjudging mirrors, but not to our Research Professor. He arrives, having printed out the posters from kinkos and flying them here. We grab a room and he marches us one-by-one to the front of the room and says, "You have two minutes. GO!" It rattles people but we get the point: we have to be flawless and unthinking. Everyone has a lot of work to do before our next drill sessions tomorrow morning and night. Becuase we do not have a projector, I cannot rehearse and recieve feedback with everyone else. I'm nervous about my speech and won't sleep well till Wednesday night.

Tuesday is spent rehearsing, running errands, and socializing. One of the big reasons for coming to this Congress is to meet physicians and professors in research or at schools for arranging clinical rotations. As a Caribbean medical student without a campus or hospital in the states, there are huge issues with reciprocity. This makes any clinical rotation outside of our "safe" hospitals nigh impossible. You have to know someone inside.

Reciprocity: You want to send a student to our hospital? Sure! Just so long as we can send students to your hospital. No hospital? Then no.

The first opportunity to meet people is tonight at the wine/cheese social. I'm not very practiced at this and balk quite often. All 20 of us have 50 business cards made up for this trip in case anyone should want to contact us. We feel pretty ridiculous owning them.

Keith Moore, Art Dalley and Anne Argur are here (writers of Clinically Oriented Anatomy). Holy shit! These people are Anatomy rock stars to me. Kyung W. Chung is here of BRS fame. If I had panties I would throw them at him. I CITE these people! EVERYONE cites these people! I have to come up with a word for nerd-groupies.

ANATARDS will do.

***If you're in a room where you are unknown, where a bright Peach, Aqua, or Royal Blue Oxford shirt. Introduce yourself to people on the far left, tell all your funny stories and charming one liners in three minutes and listen to them for ten. Then repeat on the exact opposite side of the room. Now, get a drink and stand in the middle. Strike up a conversation with someone very attractive and hold their attention. Wait fifteen minutes for the plan to set and watch as people know your name and are introducing themselves to you. I saw this executed to perfection THRICE!***

Tonight after the social we rehearse again. It is amazing how much everyone has improved. Presentations that were choppy, unsure and peppered with like's, um's and uh's are now crisp and professional. I'm incredibly proud of the group. Everyone heads to bed leaving me with three other people. I turn on the computer and, sitting, give my presentation to them. They say it's perfect and I'll do fine. I want to believe.

D-Day. Wednes-Day. I put on my nice suit with the tie that matches my slides. I rehearse the speech three more times at an average of eight minutes. I walk downstairs. The fruit bowls and bagels aren't really helping. What I need is a nice cleansing vomit. I cannot stop my hand from shaking and my heart is up in the 120s at a sit. Whenever anyone wishes my luck or mentions my presentation, the muscles of my face tighten up and I forget to breath. My voice cracks on "Thanks."

I kill a few hours with the rest of my group. They are in the other room presenting their posters. They tell me that someone was just looking for me. He asked about the student giving the mandible talk. He said he was an oral surgeon and couldn't wait to hear it, and that there were a few other Head & Neck people in the audience. My face tightens and I excuse myself. Up on the 18th floor I open my Netter and proceed to draw out all the arteries, muscles and bones of the Head & Neck and I go over in my mind how I will describe my approach on dissection, perchance I get a question on it. I am now a nervous wreck.

I go back downstairs to listen to a few of the oral presentations. The first one is amazing. The second one is even better. The third one is horrible. I feel so much better knowing that I'm no longer in the running for first or last place. I sit in the dark and deliver my speech to the back of everyone's head. It goes well.

As my time comes, everyone from SGU stops what they are doing to come watch. They call my name, I walk on stage and I can feel my heart rate dropping. I fumble with the video cord, plug in my computer, and manage to get the first sentence out of my mouth. The rest is a black haze. People are clapping and a woman in the front offers a comment. "I agree with your comment, and thank you." I have no idea what she just said.

I walk off and meet my Research Professor and friends in the back. They all have flattering things to say and each offer me a drink. I take them up on it, one by one.

Why go to Medical School: Wednesday Afternoon

2006-06-22T20:08:00.000-07:00

It's Wednesday morning. It's Wednesday morning at 10:00 and I can't stop coughing. I should be sleeping off a hangover with the rest of my class but instead I'm in the Anatomy lab with the doors closed.

My current research concerns the arteries within the mandible. Normally, you divide a person in half by saw and explore each half of the jaw. Congress is coming though, and we need a few spectacular pictures for my presentation. So, instead of the usual, I was handed a bone saw and then a cadaver. And then a flashback.

It stinks for weeks, all of these cats. I'm supposed to pick my senior classes by 5:00 today. I want senior year to be easy. I also want to dissect those stinking cats. Screw it; I'll take AP BIO. It's a year later and Jared just stole my tail. He has quite a collection, him and his bone cutter, stalking from table to table stealing the tails. I've been vigilant which is why it took him so long to defile my Mittens. I met Mittens in a plastic bag. She had been pre-skinned from wherever she came. Skinned except for her paws. Mittens.

We're kids and we're in high school and we're dealing with death. Poorly. We've worked our way up to this: nematode, grasshopper, squid (which we then grilled and ate), frog, fetal pig, and now cat. There's the kid that's too sensitive and is very disturbed by our behavior. He doesn't think it's funny when we start quoting Lord of the Flies and dancing. We call him "Piggy." I pull on the tendons of Mittens and have her kick in the air to "Da da da-dada, da da da-dada." We cope by trying to upstage each other with our indifference. Like I said, we're handling this poorly.

It's the last week before the final and I've finished all of the dissections. With my free reign I dissect what's left. I take apart the forelimbs and the scapula. I take off the hind limbs but can't free the hips. I free the ribs and all that's left is the crooked cane of the Central Nervous System and it's protecting bones.

That's what I'm looking at right now: an empty thorax, ribs intact but flailed, the vertebrae from L2 on up and his untouched head. No arms, no legs. Mittens. I've spent so much time in a book and away from the lab that I've lost my detachment. Holy shit, there's a man cut in half on the table. But I have work to do and feeling uncomforable is a waste of time. I have tricks. I focus on one spot, one square inch where I have to cut away his skin so the saw can make contact. That one square inch isn't he. It isn't a person. It's a square inch. I can cut a square inch.

The saw is dull. It's motorized and oscillating by millimeters instead of spinning. Those tiny motions mean that it cuts bone but not flesh, and there are only two spots that still have teeth. It makes the work slow and heats the motor in my hands. I have to take breaks between my sweating lips and palms. Maybe you've never had to cut a circle around someone's head, but know this: it's dusty. That's why I'm coughing. People that walk in through the far door start coughing as well, but they're reacting to the smell of burnt bone. You have to have your face near the action to appreciate the soot.

I finish my circle, insert a wedge and torque against the seam. It makes this wild cracking sound and I wonder what I've missed. I call in a professor who inserts the wedge, torques against the seam and explains to me that I am appreciating the sounds of the separating dura. wow. WOW! That's amazing! He pulls off the top and instead of feeling jealous, I am amazed. That, right there, is a human brain and I've never seen one. I'm stupefied. That's why I jostle the brain back and forward and wonder why it won't come free. For a moment, I'm an idiot again. I forget that it's connected to every corner of the body in one way or another and won't jostle free of a damn thing.

The brain lifts in the front so you can cut the olfactory nerves. A dividing membrane travels front to back like a Mohawk splitting the brain into left and right. That gets cut. The Optic Chiasm, the trigeminal ganglion, the nerve gaggle entering the internal acoustic meatus, the membranous tent dividing the calvarium into the cerebellum's part and the cortex's part like two fighting siblings. All of it: cut. It wiggles free.

This is my own instant review of everything I've read but haven't seen. Not really anyway, not like this. To finally free the brain, I have to cut the brainstem through the reticular formation. I have so much respect for the reticular formation. It's the lizard part of our brain and it's a geographical mess but beautiful all the same. And now it's in my hands. I am holding this brain and rotating it, rattling off all the sulci, all the gyri. The arachnoid matter actually looks like a spider web. I can't believe how lucky I am. I just can't. If this man were alive, I know that pushing on this spot right here would make his lips go numb. This spot right here and he would collapse. This spot: fear. This spot: memory. It's just amazing.

Another student involved with research walks into the room. I tell her what I'm doing and watch her beam. Now I get to watch her roll it in her hands, see the relationships, and slip it into and out of the skull. For the first time we really understand epidural hematomas and uncal herniations. Of COURSE that would kill you! Transtentorial herniation? That would be catastrophic!

So, why go to to medical school? Because you've never been afraid of blood. Because cutting into something that was once alive bothers you, but not too much. Because of all the places you could ever be, it's a place where you're with people that can share and celebrate something as awesome as the human brain even when you had to tear it from someone's head. Because maybe, on a Wednesday afternoon, you're biggest problem could be holding a saw to someone's skull and choking on the dust.

But smiling.

Grand Rounds 3.27

2006-06-06T06:20:00.000-07:00

Grand Rounds 3.27 are posted at the Medical Blog Network. For those that don't have the time to read everything out there, it's a great crib sheet.

Why Go to Medical School? Reason #2

2006-05-30T19:37:00.000-07:00

There's been a fair amount written about the true cost of medical school. A quick survey includes:

1) quarter of a million dollars, down the crapper.
2) 4 years for the privilege of losing another 3-5 years
3) previous relationship
4) previous waist (3 and 4 may be related)
5) all previous hobbies and interests
6) ability to have non-medical conversations (throw this in with 3 and 4)

And we slug it out, each of us, for the dream of becoming competent. I find little solace living with the knowledge that everything I have learned I will likely forget, and that everything I really NEED to know I won't see until years 3, 4, or beyond. Ergo: nothing I am learning now is making me competent. Makes it hard to give a GODDAMN about osteomalacia.

So I'm fighting back. I'm going to save each and every person out there from doing this for the wrong reasons. How, you ask? I am going to start posting here all of the useful things that I am learning in medical school. Things that will change your life, every day. After reading these, the best medical gems, do you still want to come learn the boring stuff?

This is the first installment:

Working Title: Reason #2
Alternate Title: The Grace of Defecation.

First, let's start with a little Anatomy. You're a tube with limbs. You're mouth is connected directly to your anus. Along the way it bubbles and flares into your stomach, small intestine and large intestine. Your large intestine is also known as the "colon." I didn't know that before coming to med school, and thought the colon was it's own organ just like the mysterious "prostate," which I thought meant "lying down."

Everything you eat is slowly sucked dry of the nutrition and turned into waste. It's this sloppy green paste that's found in the small intestine. Then the colon takes over and the magic begins. The colon sucks the paste dry and ages it, like the worst wine imaginable, into a brown solid. The colon fills with this and stores it until it's convenient to void it, and aren't you glad for that small courtesy?

This is my drawing of the colon (Fig. 1). It bubbles and squeezes and pushes the waste through the Ascending Colon on the right, it travels along the upper deck of the Transverse Colon, and then it slides on down the Descending Colon. You'll notice that the Descending Colon is a little "off aim" from the rectum, that is, it isn't a straight shot. That connecting segment is the Sigmoid (S-shaped) Colon and its little kink is the life-saver. Without that, it would be much more difficult to restrain your bowel movement (BM). At last, we have the anal sphincters. You didn't know there were two, did you? Yup, the inner sphincter is under your body's control. Like any Control Tower, it doesn't let anything take off until it sees a need. The outer anal sphincter is under your conscious control and has to wait for ground clearance. Once that clearance is granted, it's the pilot's decision for go/no-go.

Now let's talk technique. The pressure of building feces is usually enough to have the BM. Untrained children know this. That's not why you're reading this. You're reading this because you are a professional, and professionals keep current with the latest journals. In the event that you have passed the golden two minutes and are losing hope for this BM, there are tricks both mechanical and chemical.

Mechanical: Remember Fig. 1? Like any hand-held maze with a single marble, the trick is to coax the feces down the chute. The order is crucial. First, lean hard to your left (Fig. 2). This ensures that any marbles in the upper deck are packed into the Descending Colon. Hold that position, shake a little, use your best judgment. When you are satisfied, bank a hard right (Fig. 3). This maneuver will hopefully un-kink and straighten the Sigmoid Colon, ensuring a straight shot and maximum pressure against the Control-Tower-Sphincter. Hopefully, you get clearance.

If this does not work, you have reserves. Your abdomen is filled with your guts and sits below your lungs and heart (Fig. 4). Your abdomen is also shrink-wrapped in muscles. Both can be used to advantage. Most everyone knows that crunching up your abs and leaning forward helps. Both moves compress the abdomen and build up pressure. But without incorporating the lungs, it's like throwing a fist flat-footed. You've GOT to put your weight behind that punch! You do this using the Valsalva maneuver. It was originally developed to help push pus out of the ear. We're going to modify it.

Because you're chest is next to your abdomen, building up pressure in one builds pressure in the other. That's why a punch in the stomach (increase in abdominal pressure) knocks the wind out of you. That's why building pressure in your chest is going to knock the poop out of you. To build up pressure in your chest, take a deep breath, close your throat (or pinch your mouth and nose), and SQUEEZE! Try to forcibly exhale against your closed throat, press your elbows against your sides, crunch your abs and lean to the right. If you'd rather use a more familiar tack: blow your nose (Fig 5). Hopefully, your best efforts will bear fruit.

That was graphic, right? Now that we're done with mechanical, let's talk chemical. Certain foods help us void. I remember the first time in my life when something was "stuck" in there. My father brought me a bowl of Cheerios. I was six years old and didn't know any better. While fiber and other ruffage (think leafy greens) helps keep us regular, it's more preventative than curative. For the right here and right now, you'll need some caffeine. Caffeine is a stimulant and a diuretic (makes our urine clear). Clears the mind; sharpens the senses. It also accelerates the colon's normal shuffling action. Unfortunately, our coffee mugs are usually out of reach, and it's a little embarassing to call a coworker or family member for a cup. I'll never forget the time I ran out of toilet paper at a friend's house. "There's more underneath the sink!," he yelled. I leaned over to throw the door open and there, next to a fresh role of Downy, was a single can of RedBull. This was a man who knew what he was doing. I've kept an emergency can by my thrown ever since.

So that's my advice. Rock left, then right. Blow your nose. Have an emergency can of Red Bull. I just saved you $45,000.

Having read this, I know that each of you is thinking: "What is wrong with this person? Who sits down to write a manifesto on the bowel? With pictures? I can't believe I just spent 5 minutes reading that." To which I respond, "Try, just try, to forget it. Also, you're welcome."

Disclaimer: I have not conducted barium studies to verify my shuffling bowel theory. I am not a nutritionist or a gastroenterologist.

Grand Rounds is Up

2006-05-30T00:30:00.000-07:00

Grand Rounds is up at Kidney Notes. For those of you that haven't heard of it before, Grand Rounds is a collection of the best writing in the medical blogosphere hosted by different people each week. If you don't have the time to read everything out there, it's a great crib sheet.

Yellow Eye of Jealousy

2006-05-25T15:26:00.000-07:00

In my life, I know that I want to have piles of money and work with complicated things. In highschool I thought computer programming was the answer. That was until we left the comfort of C++. In undergrad I thought Economics was the answer. That was until my love for Micro was stomped out by Macro, it being the bigger of the two. It's been a theme of mine to love something until it was hard, and then love it much less. Finally, in medical school, I'm starting to get a handle on it.

I can be a big-picture kind of guy, but mostly I like minutiae. If you want to write a test that I'll fail, don't ask me about the type of Reed-Sternberg cell seen in Lymphocyte-depleted Burkitt's lymphoma, because I know that one. Instead, ask me what lymphoma children get. In the tree of my mind, I'm leaves without branches and it's windy in here. It's why I do well against my roommates in Jeopardy. It's why I couldn't explain any of what I've learned to my parents. It's why, as a second year student having seen the material three different times, I can't explain the female menstrual cycle to anyone. I'm young: women and babies are too big-picture.

Everything endocrine is too big-picture, and every time I see the material coming at me in the syllabus, I make a promise that this time I will achieve deep understanding. I will come to knowledge, and I will own it. Never happens. I looked over my Histo notes from a year ago and saw to my horror that I had labeled the anterior pituitary as the hypothalamus and had kept that distinction throughout my notes. Those 10 pages of stupid stared at me; mocked me. "Remember in high-school computer class when you wanted to write programming code? Remember when you cried and quit over nested loops? I remember. I remember you're an idiot."

Economics is beautiful. Nested loops are beautiful. Endocrinology is beautiful. It's all about homeostasis and balance and listening and I suck at it. I think that the Liver and Biliary System is the most amazing thing in the body and I want to study it until I'm yellow in the face. I'd love to be some species of Endocrinologist but my M.O says that I'll shrink from that dream and instead become a surgeon. Those who know me say that I'm instead a surgeon with hormonal delusions. At 24, I'm still blaming puberty.

Next week will be my forth attempt. Every time I have failed has more firmly cemented my learning curve. And though I remain optimistic that this may be the effort that changes all of that, I cannot ignore the brutal truth of those two standard deviations in front of me.

I will probably fail at the academic side of medicine. I will instead marry an Endocrinogist, become a surgeon, and look with jealous eyes at the Anesthesiologist. He'll probably have his computer open. I'll lean over and see that he's writing a computer program for an economic pet project of his that he nursed through medschool, which came easily for him. And while he's kicking my dog and getting married to my first girlfriend, I hope I remember that I'm thankful for being good at anything.

So I'm not big-picture. The sooner I make peace with that, the sooner I can look at the glint from my shiny scalpel and forget about it. I'll sing the scalpel song that Todd from Scrubs taught me:

"Dum, did de dum, did de dum, did de SHINY SCALPEL!"
"Dum, did de dum, did de dum, did de GONNA CUT HIM UP!"

Jog-22

2006-05-22T17:25:00.000-07:00

In medical school, I have options. I can do a few of the following:

1. Stay healthy.
2. Get As.
3. Have a healthy relationship.
4. Have a social life.
5. Do research.
6. Get tan.

The interplay is fascinating. When I go for As and Research papers, I gain weight and lose my social life. When I'm trying to be a good boyfriend, research and books go by the wayside. Also, if I'm happy in the relationship, I gain weight. I could get tan, but then I'd just be round and brown. Plus, being tan requires maintenance, and if I was capable of that then I wouldn't be round. Staying healthy was never really in the cards.

3rd term with all of its free time was my only real shot at nailing more than three items from that list. Funny then, that I remember so much of what I learned then as training for getting angry at ungrateful patients (that I haven't had) over not following my advice (which I haven't given). So what if a smoker comes in complaining of a cough for the last two years; I'll feel sorry for him. I'll bond with him over my obesity and diabetes. He has his 30yr pack history complicated by chronic pneumonia and I'll have a 20yr donut-breakfast history complicated by a double-chin.

Why the focus on my health? Today I sat at the computer and noticed that instead of the effortless inhale that I've been so used to, I had to fight against a roll of stomach squeezed against my belt buckle. "These pants must be too tight." In my empty apartment, I look left and right before opening the belt and letting loose the top button. I took a deep, satisfying breath. "That's better."

About five minutes passed before I had my running shorts on, house keys in hand. I went for a jog. I'll never again lie and say that I "ran from campus to the roundabout" or "went for a run." I've been friends with too many cross-country runners and track athletes to think that the way I lurch forward while shuffling my feet constitutes a "run." I know just as well as they do that I might travel faster if I was speed-walking.

I should be better at this. I used to jog in my previous life back home. It's harder (for me at least) without a running partner, and I tried to get my sister running with me. She, being a little overweight, would have none of it. "People will see me and think that I'm fat." Which is true. Most people love to take a cheap shot at a stranger. Before I had trouble breathing, I remember seeing an overweight person out jogging and thinking to myself, "Someone should tell her that it's not working." Not now though; not since having sisters. I see people jogging and think, "Good for them. Jogging sucks."

And I would never do it to stay healthy for health's sake. Instead, I subscribe to the Yo-yo plan of jogging:

1. Jog and be miserable until skinny
2. Stop running and begin slow descent into happy fatness
3. Become disgusted with fatness and buy a new pair of running shoes (and jog in them)

The problem with this plan of mine is that once my body adjusts by pumping more blood, burning more fat, and increasing my basal metabolic rate I've also developed a constant gnawing hunger that rears its head 20 minutes after any meal. And dammit, if I was strong enough to say 'no' to that stupid hunger in the first place I wouldn't have overeaten and I wouldn't have a few pounds to lose.

Frustrated with failure, I do the normal thing: run for a half hour, drink a beer in the shower, and call it a day.

Dear Fantastic Four

2006-05-20T18:55:00.000-07:00

There are four people that have admitted to me that they read this thing, and I need their help. Thanks to some accidental work with the school's Orientation office in New York, I have the bent ear of the people that stock our bookstore. I mentioned to them that I wanted to buy some clothing that showed off SGUSOM back home but I didn't like what was available. So they called me out on it.

"You don't like it, well what should we have instead?" So I have suggestions of my own. But that's just going to fill the place with things that I like. So if you have an opinion, please post a comment and I'll make sure that it finds its way to some of the higher-up mucky-mucks.

Also, I'd love some t-shirt ideas. Here's the dumb stuff so far:
"Welcome to the Rock"
"Eat at patels"
"It's GrenEHda not GrenAHda"
"I (heart) GND"
"I (nutmeg) GND"

I also want to suggest shirts and hats like these:

A First Place Cheese Log

2006-05-20T17:28:00.000-07:00

My sister is graduating this Sunday. She's the last in a long line of grey hairs for my folks and I'm so proud that she's leaving the state for Regis University. Get free, sis. Get free.

Speaking of freedom, the hog squeals again. I dumped $300 into my moped to get it running again and it feels great to be cheating death on a daily basis. Just yesterday I was trying to pass someone that decided to swerve violently in front of me and slam on the brakes in hopes of causing an accident. Thank you slackline; the balance you taught me saved my life. It was over before I knew what happened, but the students in the car behind me let me know:

"He tried to kill you. You tried to swerve out of the way and your bike went sideways and skid forward a yard without flipping on top of you, and then you went to the side of the road. He looked back at you and screamed something. It was definitely on purpose. Is your foot ok?"

I look down to see that two of my knuckles have been ripped from my foot and the holes are bleeding. Sandals are not protective. I thanked them for checking on me and continued driving towards the nearest bandaid. I think that when my life really is in danger I'm going to be robbed of the whole "life flashing before the eyes" bit since near as I can tell I just draw blanks. The bike is now for sale.

The exams I studied so much for went well and while Path still remains, Microbiology is over. I learned some amazing things in that course and am sad to see it go. A few of the gems:

Military officers do not contract gonorrhea, that's for enlisted men. Officers are afflicted with "bacterial urethritis."
I rarely spell "gonorrhea" correctly. In fact, all medical words that contain an "h" have to be preceded by "rr." Diarrhea, amenorrhea, rrhiccup, and so on.
Doctors are paid by the syllable and charged by the word. That's why you'll hear "Pyelonephritis by hematogenous spread" instead of "The bacteria got to your kidneys by your blood." If each word costs a dollar and each syllable pays a dollar, the first sentence pays $9, the second sentence pays $4. So as a physician, I can either be plain-spoken and poor or rich and confusing. I think I've found my calling.

I'm not ready to start studying again and am trying to stay distracted. This includes looking online for a tutorial on how to whistle with two fingers. I have technique but not power. I'll keep you posted on how it goes. I still say the alphabet backwards once a day, to stay sharp.

I finished the edit on my research paper and sent it back. Two days ago I received notice that it was accepted. I feel sorry for everyone with a birthday that's 4-6 months away, because you're getting a copy of the Annals of Thoracic Surgery that you DO NOT WANT and WILL NOT READ but are GETTING ANYWAY. I found out that I have one of the oral presentation slots for Congress this summer. The reserach congress is in Milwaukee. I feel like Wayne and Garth when "Delaware" came up on the blue screen.

I'm up against 14 other students, one of which won the prize last year. I have it on good authority that the boy whose voice cracks the most often will win this year. Should be fun. I'll bring back a cheese log. A first place cheese log.

So much depends upon...

2006-05-17T21:55:00.000-07:00

William Carlos Williams once wrote that "so much depends upon a red wheelbarrow, glazed with rainwater, beside the white chickens." And he was an idiot. So much depends upon momentum, and every med school student knows this.

It usually happens two or three weeks before an exam, but you'll see every student stay later in the library, talk less, take shorter meals. They're switching into higher and higher gears of focus. It takes a while, but the hope is that the week before the test they'll be operating at their maximum, absorbing everything, learning like a machine. Once that test is over, they don't celebrate or take a day off. They hunker down for the next four days, never changing gears, in order to tackle the next exam. Momentum is so valuable and so hard to build that losing it over a celebratory beer seems irresponsible. And it is.

Once the week of tests is over, most will gather around a bar, drink the weekend away, and gladly lose all the ground that they've gained. Others will relax for a day, and then start on new material with the momentum that they refuse to lose. And this works, for a while.

But the thing that you learn afterwards is that so much depends upon balance. Studying straight, 14 hours a day, for five weeks and you start to burn up and burn out. You lose the joy of learning. You hear the stories of what you missed that weekend and soon enough you've lost your precious focus. It's times like these where you have to push the responsibilities away, go out, and remember how funny life is.

Tonight I went to Stewart's, a local bar on a floating dock. Students are buying 16 beers at a time because they hate waiting in line, a lot. The men's bathroom has two urinals, and I feel humiliated every time I have to use that one that is obviously for children because I'm not 6'10". At the end of the night a young couple knocks on my door asking for ice, and promises that they'll bring me some ice tomorrow. I try to explain to them that I can just grow some more but they insist. Fine, I'll take your ice cubes.

This recharges my batteries. This is what I'll laugh about when I'm locked in the library for the next three weeks rebuilding my momentum.

"So much depends upon a young couple, sloshed with warm liquor, begging for ice."

Take that, William Carlos Williams.

Hospitals For 3rd year Clinical

2006-05-16T12:34:00.000-07:00

Approximate Spots in each hospital for students

Elmherst 24
Jamaica 18
LICH 24
Lutehrn 32
Maimo 32
NYM 50
Barnabas 28
Brookdale 16
Flushing 12
Highland 12
Jersey 8
San Joaquin 8
St. Francis 6-8
St. joseph’s Mercy 4

USMLE review

2006-05-16T12:12:00.000-07:00

This is from a talk given by Dr. Moninger at St. Vincent's. It's rough and I'll add to it as I approach this hurdle myself.

Most important things

1. Good 3rd year grades
2. letters of recommendation
3. previous research
4. usmle step I score
5. 1st and 2nd year grades

-on test day, wear your least favorite long sleeves shirt
-you can’t mark on scratch paper, mark on plastic sheet (laminate a sheet of paper)
-cannot bring in baseball cap, electronic watch
-they videotape you while taking the test

passing is around 57%
avg is around 65%
best is about 80%, this is the best anyone ever does

-you will feel bad after exam even after you studied hard
mean is around 215-218
passing is 182

question types
-vignettes
-pictures
-charts
-calculations

60% of exam is new every year, but they compare everyone on the 40% of questions before
just to get any residency, you want to score above mean
if you get in top 75% of usmle, you can go almost anywhere (225 – 230)

-questions are written by a committee, all members of the committee must agree on each question

-questions based on core information, not research projects
-if there is a disagreement about the answer, the question is gone

question breakdown (approx)

70 - path
50 – phys, micro, pharm
40 – anatomy, behavioral science, biochemistry

-most medical students take 4 weeks to study for step I and take it right after you study, if taking review, take a 1 week to consolidate information
-gpa is more of how quickly you can stuff it in
-I recommend studying from 8 am to 5 pm

5 rules for doing well
1. know the material well that you study
2. keep it simple
3. know differences rather than similarities
4. do half hr of micro and pharm every day
5. rehearse out loud

do half an hour of micro and pharm each day
-med students want some sense of accomplishment
-just do 3 new drugs a day for 20 days will significantly improve your pharmacology score
-doing 15 new drugs a day for 5 days will not significantly improve your score

Rehearse out loud
-we tend to fool ourselves when we read quietly to ourselves
-the real test of knowledge is talking

Good news
-you can study the material you learned here and do very well
-if you created course notes or in some way condensed the material, this would be the best way to study from, sometimes the obsessive and organized people win

4th Term

2006-05-05T09:37:00.000-07:00

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Good luck with 4th term. Lot of work, lot of fun, lot of time in the library.

These courses are going to overlap a great deal, mainly with infectious agents, immunology, and diagnostic procedures. The review books that were the most helpful: First Aid for USMLE, Micro/Immuno BRS

MICRO (5cr):

The department does an excellent job on some sections and horrible on others. You really need another resource to handle and structure the information. I used the First Aid for USMLE step 1 book and the Micro/immuno BRS. I highly recommend each. I did not buy the Micro text. Too much information. Several times in the notes, a reference will be made to a table or figure. When it came time to prepare for the tests, I just checked it out of the library, found the figures and moved on. Save your money.

PATH (13cr):

Path is challenging because of the alien teaching style (group lab work) and the volume. Topics in Path are broken into Modules. You will have 6 before the first exam, 4 before the second, and the rest for the final. Each module consists of around 30 slides that are descriptive of different pathologies. Among your group, you will split up these slides, go to the library to prepare a presenation on whatever you were assigned, and then present to the group. For the first half hour of every lab you are free to say as many wrong things as you want, but then the tutors descend. Once present, they will listen like hawks for the first piece of stupid to fall from your mouth, and they will then punish you for saying it by asking you questions that you cannot answer and slowing down the group (your fault). Then, since no one could answer correctly, your tutor will explain the problem to you. Don't get hostile towards the tutor; it's only because you screwed up that they had to fix it. That said, some tutors will insert comments here and there and hijack the lab. If this isn't the way your group wants to work, all you have to do is say so and the tutor will stop. They're there to help you, I promise.

So if the members of your group take their responsibilities seriously and don't try to bullshit through an answer, things will run smoothly and you'll cover your slides in the time allotted. If not, then there is going to be some disappointment and hostility when a pattern emerges. You'll have to come in on days off to finish when you could be studying. For this reason, I beg you to pick a Path group full of people that you think will DO THE WORK. If one of your best friends is a lazy bastard, then she needs to be in a group with her kind. Don't feel bad about any of this: the less work they do, the more work you do, the harder path is for everyone. Groups on top of their game are having fun. Be that group.

The biggest problem that hits the Path student is Volume. VOLUME. There are going to be three and four and five good sources for information, and if you try to pull the best from each to make your notes then you can kiss the rest of your life goodbye. With all that volume comes the mistake of thinking that it is all important. It isn't. For example, when researching C.neoformans, you could either write a book or you could write:

"small cell, thick capsule, india ink, AIDS meningitis."

When the test comes, it's hard to memorize 300 books. One liners are just easier for this kind of volume. I'm sure you'll find your own happy middle.

As for books:

The Path manual with black and white pictures is available in color .pdf on angel. I never used the path manual that I bought and instead worked from my computer. So I wouldn't buy it a second time around. However, many people used it to write down their notes in lab, and then would also annotate with the lecture handouts. The great advantage of this is that ALL THEIR INFORMATION WAS IN ONE SPOT. Having three different books open along with dr.google can be a bit overwhelming, especially when it comes time to study.

Make sure you get the macdaddy. It has audio files (Sokumbi's Reviews). Indispensable. It also has every lecture slide completed in PowerPoint format from previous terms, so you can get an idea of what the hell you're supposed to be doing that first week. It's also the great equalizer if you're confused by something your tutor said that week.

Big Robbins: amazing text. Pocket Robbins: also amazing. Bought both, used both every day. I also bought the Pathology BRS but it was too much. I stuck with my Robbins books and the notes and did alright. DO NOT BUY THE ROBBINS REVIEW OF PATHOLOGY QUESTION BOOK. Look to links...

Now for the websites.
Pathguy: Path professor famous for his easy explanations. Architecture of the sight is a little odd.
WebPath: Website with quizes, timed quizes, quizes with slides, path case of the week. Amazing preparation for the tests. Has all the questions from Robbins Review of Pathology, so you don't have to buy it.
eMedicine: Went to this website almost every damn day.

Clinical Skills:

Yup, you get to hang out with your Path group one more time. All in all my favorite course of the term. I bought Pocket Bates' and a stethescope. The PD kit was a little too expensive for my tastes and I wasn't won over by the tourniquet and tongue depressors. And what use I'll ever have for a BP cuff, well, I may never know. Of course if everyone decided that then we'd all be screwed since I did rely on at least two people in my group of 6 to have the kit. My vote is that the CS program should supply the kit for labs and tests themselves. End rant.

The Powerpoints on angel are good review and a video is shown at the beginning of every lab. Channel your inner-trained monkey and you'll get through it. When you're examining your classmates make sure you go with confidence. The tutors can smell your fear and uncertainty.

Remember that the majority of your CS grade comes from Saint Vincent's, so it isn't the end of the world if you have to come unprepared every day in order to stay current in Path/Micro.

NUTRITION:
I have yet to begin Nutrition, but trust the people that told me to just buy the book.

Hope it helps, topher.

Anne

2006-04-30T10:24:00.000-07:00

I worked in a hospital for over a year on the Hem/Onc floor. We were the highest Onc floor, which meant we had the most terminal patients save for the ICU just above us. The night shift was a long shift, and we would pass it at the nurses' station talking about nothing. The nurses would tell me about each patient or go through the charts with me (which might be against JCAHO, might not be) and I'd try to absorp what I could. When a patient needed to go for a CT scan, I would take him in his bed or wheelchair and sit behind the consoles watching the slices of their body on the screen.

After a year, even without any training in Anatomy, you get an idea of which cancers are the worst and what they look like on the CT. You know where each organ sits in the body and what it's supposed to look like. And more than all of that, you can tell when the CT tech is holding her breath and the physician brings his hand to his mouth that this person is in some trouble.

So it was with Anne. She was a little younger than me, a year maybe. She went to a college that I knew well. We might have known some of the same people. She came to our floor with her parents and sister. I admitted her, went through my "this is everything" speech after I took her vitals, and let her family know that I was only a call-button away. She was beautiful and healthy and trying to make the best of it.

The admitting physician called me over with a wheelchair and I took her down to CT. She asked me where I went to school, if I was a nursing student or a med student (neither at the time, but hopeful), and my age. We had a lot in common. I helped her onto the table and then went in the back with the monitors. The Tech held her breath, the doctor covered his mouth. I saw what they saw: hundreds of tumors in her liver. "Poor girl. She's so young."

Everyone was speaking less as I took her upstairs and she knew. When we were alone in the elevator, she asked me, "So. What do I have?"

I didn't say. "I'm just a tech; I can't read a CT." Again, she knew. I brought her back to her room and she said, "thank you." My shift ended a few hours later, but not before every nurse on the floor knew about this girl.

I came back the next night and I could tell that the doctors hadn't told the family. I came back the next night and off the elevator I could hear the papers moving at the secretary's desk above the sounds of the nurses' conversation. They had told her. I looked at the assignments and she was my patient that day. I rounded, got all my vitals and emptied urine and talked to families. Her room was the last. I came in ignorant and smiling because I'm not supposed to know what everyone knows. Her mother met me, told me it had been a hard day for the family, and that the nurse already got the vitals. "If you need anything, please..."

"We know. Thank you."

She became sicker, friends started to visit, and then she left for a different hospital. I never found out what happened to her.

-------

Working in the hospital, that first week, you're obsessed with knowing everything about the patients. You write their first and last names on your record sheet, you know what they did for a living, and you look at your insensitive coworkers that don't know their patient's names until they read their wristband. They have patients 3, 4, 5, 7, 9, 10, 14, and 15 instead of Mrs. Hayes, Mrs. Bopp, etc. You tell yourself that you're going to remember the names of every person. You're an idiot.

I'm no different. I tried it and slowly they slipped away. Then I started forgetting the names of people that had been on the floor for weeks at a time. Then I couldn't remember the names of the people that had died on the floor, or the ones I had watched die. Then I couldn't remember even 10 of them.

But I've always remembered Anne. Everytime I feel the year I spent in Hem/Onc slipping away and I can't remember the nurses' and the doctors' and the patients' names, so long as I remember Anne I feel like I haven't lost it all. And I wonder how she's doing. And I worry about her often.

Bet a Beer on It

2006-04-28T18:35:00.000-07:00

I assume you want to do well in medical school. A trick I've learned since coming to Grenada is this: talking helps. After you've read about the sympathetics and the parasympathetics, spent some time in the library committing the topic to memory and worked through a handful of practice questions you start to feel comfortable with the material. Then you find yourself in a conversation with a classmate, trying to explain the concept to him when you realize: I don't really know this. You stumble over your own explanation and a couple of excellent questions later you think about all the time your spent working on your wrong answers and you want to cry. At least I do.

That was my second week of class in Anatomy. Afterwards I started studying with the guy that asked the great questions and made sure that we talked through all the concepts every couple of days to keep each other on the ball. It shouldn't surprise anyone to know that it works like gangbusters. After that we found another person that asked great questions and he was studying with us too.

We were lucky to find each other early on, stick to our schedule for covering each course, and to end up testing well. With the confidence of doing something correctly, you start to see the game emerge between the students and teachers. You begin to read the notes and see the test questions buried inside them. You start coming to group review with questions that you've created to stump your friends. They come with questions of their own and you fire back and forth. You bet a beer that such and such will be on the test. You bet three beers and four beers. You have to get out flash cards to keep track of all the bets. And at the end of it all, exhausted from the exam, you meet at the bottom of the hill in front of the D-store to tally-up and celebrate with your class. It's intoxicating.

Remembering the thrill of learning and the excitement in the eyes of a person that "achieves understanding" of a difficult topic is what you cling to when two solid weeks of exams loom two weeks away and you're holed up in the library hating the clock as it ticks past midnight. You remember that and then you see an interesting detail in the notes that you bet your friend doesn't see. And you write it down. And you think about that beer you're going to win.

Phlebotomists 'R Us

2006-04-25T13:24:00.000-07:00

I knew back in the hospital as a tech what all nurses and patients have known since time immemorial: doctors can't draw blood. They're horrible at it. Shouldn't matter, right? Doctors have other much more important things to do like Chest tubes and Lumbar Punctures and all the other things that make an aspiring med student salivate. As an underling, I was almost grateful that I could be better at just this one stupid thing. What's funny is that patients don't think that way. When a physician walks in and starts stabbing and missing, they change in the eyes of their patient and become a little less Superman and a little more Clark Kent. Too bad that it happens over some stupid blood draws.

But here's what really gets me: they get to pull ABGs! An Arterial Blood Gas is a collection of oxygenated blood from a pulsing tube in your wrist. It's deeper than a vein, harder to draw correctly, and with more serious consequences. Patients wnjoy this even less than a vein puncture. So since my first days in the hospital, I've wanted to know exactly what kind of training future MDs get in the arts of nursing. Well guess what...

OUR CLASS JUST DREW BLOOD! That's right, 300+ students that have never held a needle were shown a 10 minute instructional video explaining what happens when nothing goes wrong, and then they were given a tube, tourniquet, needle, cotton swab and bandaid! We were placing bets on how many students would pass out, vomit, or just walk out.

Guess what: THINGS WENT WRONG! Needles with vacutainers still attached were pulled, sucking tissue with them; veins were blown and swelling under the skin with tourniquets still tightly fastened; and hands were shaking so violently that the needle was scrapping back and forth before it had the chance to hit the target. There's a rule among phlebotomists that it takes 100 draws to get comfortable and trully competent. With that math in mind, 3 people had correct draws today. Pretty respectable, I think.

Our group faired well: three shaky hands, two blown veins, only one blood spill onto the table and a lot to laugh about. Good day all around.

P.S. If you need a summer job that pays within reason: phlebotomy is the way to go.

The House Effect

2006-04-24T09:50:00.000-07:00

It's probably unfair to call this the "House effect" because this problem predates that show by a few decades, but I'm going to anyway.

House effect: obsession (of both teacher and student) to know (in detail) the aspects of a disease that you should never see in your entire life.

I learn that 95% of all tumors of the gallbladder are adenocarcinomas. Ok, I'm fine with that. What I'm not fine with is a page of notes then devoted to the minutiae of that remaining 5%. It's not necessary. It wasn't necessary after I learned that 90-95% of lobar pneumonias are caused by strep. pneumoniae, and it isn't necessary after I learn that 98% of all peptic ulcers occur in the antrum of the stomach and in the duodenum. You can keep your 2%; I don't want to know it.

Under the same logic, I should NEVER HAVE TO KNOW ABOUT ANTHRAX. I'm staring at two pages of Anthrax notes right now, and while I feel very prepared to hold my own against a talking head on FOX NEWS, I sure as hell know that I will never put this information to clinical use. And let's say, for argument's sake, that I did? Let's say ten years from now I see a case of anthrax: I'm calling the CDC and letting them cough up their lung (which is what everyone should do, regardless).

The logic of the last 5% is pretty simple: if you treat 100 patients you'll see it 5 times, so you need to know it. I understand and respect this. I also understand that all the truly useful things I ever learn will be on-the-job. So if during rotations my Resident decides that I really need to know the 5%, then I'll know it. But just imagine how much more useful it would be if every medical student walked out of the first two years knowing 1) the top five causes of everything or 2) the causes that cover 95% of cases. Instead, I feel like I lose sight of the forest because the people writing my tests think the ant on that piece of bark on that rare tree is too interesting to skip. So I should probably know that instead.

Anatomy

2006-04-23T19:47:00.000-07:00

So congratulations! If there's any course that signifies medical school to the undergrad, it's Human Anatomy. After this you should know every bone in the body, every muscle that moves them, and every nerve that orders them around. And I'm kidding. You will cover a fair bit of it, know some interesting clinical presentations, and be able to explain to your friends back home what "fight or flight" is all about. And isn't that the goal? To sound impressive?

This course has changed a bit since I took it. Instead of having every student slave away in the lab cleaning fat for a grade, the department now pro-sects (a professional dissection) every structure of interest and then takes you through ID, relationships to neighboring structures, and pop quiz. I think you get to dissect the first day on a space that's impossible to screw up too bad: the superficial back. Of course this didn't stop me from cutting all the way to the ribs on that day. And yes, an announcement was made to the class that I was an idiot.

If you've taken the course already and want to freshen up or are taking it for the first time and want a heads up, this site is great. It shows the dissection of the entire human body in easy-to-download quicktime movies. Another great website is the University of Michigan site. Several classes have lived and died by their practice quizzes. Get a wrong answer: it tells you why you're wrong. Most students click all the wrong answers anyway just to see what they might be missing. And for those of you with the free time to dream of overachieving, they have surgical videos as well.

Now for the books. The school gives you the combined oil paintings of Frank H. Netter, may he rest in peace, and the "Baby Moore" Clinical Anatomy book (make sure you read the Blue Boxes). For a book with a more gross approach to anatomy, the Color Atlas of Anatomy by Rohen is pretty clutch. Some students go so far as to buy Clemente's but between you and me: that's overkill. For those out there who like coloring books, they have those too.

The school produces their own Anatomy manual in binder format and all of the lectures are online as PowerPoints. Review at your leisure.

Strategy for covering all of this material? Who knows. The first week or two of classes is light, giving you every opportunity to study like an idiot and learn everything incorrectly. It happens, don't sweat it. Instead, learn about the different ways to study and make a trip to the Department of Educational Services (DES) office and have a chat with them. I did both; both helped. Another thing you'll probably due is attend too many DES sessions (tutored by students that are 4 months ahead of you), artificially boosting the confidence of said tutors until you cut back and find your rhythm. Best advice I received was 1) draw everything and 2) study with people smarter than you.

It's going to be the first hard class of medical school, you will get through it, and look at it this way: by the final you will be able to write out all 208 bones of the human body on a table napkin and not bat an eyelash, and that's what medical school is all about.

Black Belt in Notejitsu

2006-04-22T07:44:00.000-07:00

My friends and I laugh at ourselves when we think back to undergraduate. Somehow, we were convinced that it was hard at the time. I remember talking to classmates after a test thinking, "Wow, I studied for six hours in the library for three straight days to prepare. I'm exhausted. I feel like I earned an A." I wasn't lying.

Well welcome to medical school. A friend of mine went out on a date with a med student who had to cut the date short so he could get back to the library, and he wasn't blowing her off. I remember Uncle Neurophysiologist telling me that my life would be in a book, my weekends in a book, my nightlife in a book. I didn't believe any of this. Well the rumors were true.

Medical school is the beginning of your life-long devotion to learning. You will spend the majority of your next two years (preclinical) in the library on a Friday night learning the morphological differences between Tropical Sprue and Whipple's Disease. You will be a student of the 17th and 18th grades. And you had better be an expert at studying.

You will hear about the Cornell Method of note taking. You will flirt with concept mapping (CMap is the best program I've seen). You will swear by flash cards until the rubberband breaks sending your brain spilling across the floor. You will stick with the outline style of note-taking you learned in high school. You will see someone read the notes with a highlighter, achieve understanding, and then put it away until the test comes. You will hate that person. You will see someone that highlights too much, with too many colors, and has colored pens at the ready. You will see people with 3M sticky notes covering their cubicles, the organization making sense only to them. You will see people with too many other sources stacked around them, drowning in it.

Rarely will someone go to the student help center to learn about note taking styles and strategies. And that's a shame. You're going to study more and be tested more than any person that you know outside of this world. It makes too much sense to say that you should become an expert at what you do. So my advice to anyone in medical school or thinking about the plunge is to go to the bookstore, research studying methods, talk to an expert, and earn a black belt in note-jitsu. It's going to be a long hard fight.

Public Speaker

2006-04-21T13:44:00.000-07:00

In Pathology we have Clinicopathologic Cases. They're cousin to the SOAP notes of Physio were a patient on paper presents with problems that neatly fit into that weeks' lessons. In contrast to the SOAP note, the CPC is mildly terrifying. Our case this week is a 20 year old male that hit a pothole while drunk on his motorcycle and stopped at a tree, suffering serious trauma, a compound fracture with significant hemorrhage, and possible spinal injury. You're working diagnosis at this point is "idiot".

EMS arrives within the platinum ten minutes to deliver care. They get him to a hospital, work on his leg and get all of his vitals straight back to normal. He dies anyway from respiratory failure. Working diagnosis should now be "tree allergy."

Everyone in my class of 350+ has this case, and while all of us think we know why he died, none of us wants to prove it. No matter, because our professor reaches into a bag with 350+ names and pulls one unlucky bastard to the front: not me. You can smell the collective exhale of that many students while they cheer the lottery winner to the front. He rereads the packet to kill time, asnwers what he can while getting a few things wrong, and is appropriately nervous. People like him and empathize, so he gets to avoid the tough questions.

Afterward I run into a few AAA-types saying how they wish they'd been called and were thinking about volunteering for the next CPC. I hope they let you; it'll be a blood-bath.

This is what I think about when I think of doing clinicals in a year. Lay low, have the right answer if they ask you, but don't be a dick about it.

Asthmatic Kite Runner

2006-04-20T12:38:00.000-07:00

When I was kicking around the idea of being a doctor, my Neurophysiologist Uncle told me to read every book I ever wanted to read before going, because you wouldn't ever read for pleasure again. I scoffed as I often do at such unbelievable things. Well, the rumor was true.

Today on Graham Azon's blog (over my med body) he posted a pdf about a woman with perfect autobiographical memory for the past 26 years. I clicked it open and saw that it was 15 pages long. Well, I'll never get to know about that lady becuase I don't have 15 pages of free time.

And that's the way I look at books now. A 350pg book isn't some amazing journey through the life of such n such; it's 4 days of waste with a 3rd place ribbon on my test (C). Nope, I'll never know what it's like to fly kites in Afghanistan. Too bad. Instead I'm learning about Asthma.

Though flying a kite would hit the spot right about now.

The conversation with yourself

2006-04-19T14:43:00.000-07:00

I remember the early days of first year when the work was hard and the labs were long and we had our hands in cadavers and our heads in biochemistry and we felt like some of the smartest people in the world. Everything is great, you're dating new people and forming strong friendships and then BAM. The work is too much that week, that night that day. And the pesonnext to you is getting it. And they're excited the way you used to be excited and life still feels easy to them the way you miss it. That feeling will hang around your neck as long as it needs to. It'll keep hanging there until you have a conversation with yourself.

Why am I doing this? My friends back home are starting their jobs and making money and buying new things to make their apartments look nice so the people will want to sleep with them and I'm missing all of it. This is first year. It only gets harder. Why am I doing this? I could quit. I could quit right now and I'd only have $40,000 in debt to pay for my mistake. It might just be worth it. Maybe I should quit. Maybe this was a bad move.

And of course maybe it was a bad move for you. Maybe you shouldn't be here and the smartest decision of your life would be leaving right now and cutting your losses. People stay though. They stay because they know a moron the year ahead of them, so figure it can't be that bad if THAT GUY made it. Some people stay because they don't know what else they'd do with themselves. Some people stay because as much as it sucks, they can't do anything else. The point is that the doubting doesn't have to stop because you want it to.

I'm almost half way through 2nd year and I'm having a bad week. I don't feel like I'm learning any of this Pathology and I've ignored Micro for three weeks now. It's all going to catch up with me whether or not I catch up with it. And if I don't suck it up and pull through then it's going to sting real bad when I see my test. Feeling beat up and stupid is no fun, and it's frequent enough that you often feel like quitting. But I remember exactly where I was standing on campus in first year where I had that important conversation with myself. And I remember my answer.

So I'm waiting for it to get better, plugging away while it isn't and telling my problems to a stranger. All of it helps.

Everyone's a Ken Doll

2006-04-18T15:09:00.000-07:00

You'd think that at this point in our lives, as med students, that everyone would be comfortable with penises and vaginas. We are not. I remember as a first year in Anatomy lab there being seveal students that never laid a scalpel on the body and remained on the margins, their scrubs smelling just as bad as everyone else's but missing the flecks of flesh. This would be laughable if it weren't encouraged. Pick up a medical textbook and more often than not, instead of an anatomically correct drawing you get a Ken Doll, complete with nondescript genitalia and breasts that ride the border between overweight guy and underdeveloped girl.

So I was surprised today when I walked into Clinical Skills to see a video of a very curt Irish physician giving a full pelvic exam to a very hairy Jewish girl. I was more surprised than anyone, having heard so many stories about giving pelvic exams to manequins instead of prosititutes like the other medical schools get to do. I don't know where I heard that, but I did.

So after a perfectly graphic demonstration of a female pelvic/anal/breast exam was an equally graphic male example. Checking for an inguinal hernia does not look fun.

"With your right index finger grab a section of free scrotal tissue and feed it up and into the inguinal ring, following the spermatic cord, where you may appreciate the internal inguinal ring."

Now I applaud the folks that put the video together and the phsicians and patients that volunteered, but everything was still a little off. Hospital work, though repetitive and disgusting, does have a pot of gold at the end: you get comfortable. It took my around 11 months to get really comfortable to the point where I could talk to patients about their dying and regrets and family. Being able to speak frankly and honestly with a person that near death is special and should be mandatory. Imagine you're dying slowly, having the chemo-book thrown at you, and everyone's too busy being motivating and positive to say that, "Yeah, you're dying. How do you feel about that? What are your biggest concerns and what do you want accomplished in the next few months?" Sure you throw a chaplain or two at them, but they aren't part of the day to day care. That job should instead fall to the day-to-day staff: your oncologist and nurses and hell, even your techs.

My point about all this is that those physicians and patients were really off. The patients were too happy and compliant about their anuses and urethras and the physicians weren't distracted enough. Your proctologist is bored with your anus. He's seen thousands of them. Same goes for your OBGYN. The patients are not happy about your finger in their rectums. That hasn't happened to them thousands of times and they want it to be over. They certainly don't hop off the bed and shake your hand afterwards.

I'm not asking for much, just a doctor who'd prefer to do a quick exam and say your fine and a patient who can't wait to hear it so that she can leave. They were all just too happy and it reminded me of the embarassed students in anatomy lab that didn't want to see what a body really looked like, just like the video wasn't showing us what a rectal exam is really like. I don't blame the actors; I blame the director.

Soon, I hope, medical school will stop presenting the "Ken Doll" version of things and let Barbie know what she's really in for.

Shake Hands

2006-04-18T14:12:00.000-07:00

I'm a Caribbean medical student. Like most people I tried to get into medicine in the states and was rejected for perfectly good reasons. Chief among them were:

1) immaturity
2) poor scholastic performance in spite of the tools to excel
3) horrible recommendations from teachers aware of points 1 and 2.

Despite those failings, I was done with mediocrity and standing still in life. After graduating I tried to find work in the medical field for a better shot at a second application cycle. The job that I eventually landed was a Patient Care Tech. in a very fancy hospital. The requirements were that you have:

1) GED / High school diploma
2) no drugs in your urine
3) no criminal history
4) no better options

I didn't even get this job cleanly, but instead with an inside man who knew my family and thought I was a good enough guy. It was one of those great times when someone in the position to help sees a little of himself in you. I was glad for it. I worked that job alongside full-time nursing students, grizzled nurses, and a revolving door of people that weren't rejected early enough.

My life consisted of 12 to 16 hour shifts at night on a Hem/Onc ward. In case your curious, the nicest hospital floors are usually on top, except in the Onc building, where everyone is trying to work there way from the ICU on floor 9 to terminal Onc on 8 down to the lobby where people are smiling because they get to go home. I spent 13 months there learning to love patients and hate patients and become used to the worst juices of the body. Like most people seeing that world with fresh eyes, I have several anecdotes about life in Term Onc and I'll write about them in time, whenever I have a slow day in the present. But we're just getting introduced now.

After 13 months of working the same job on the same schedule with the same part of your brain asleep for all of it, you learn a better answer to any admissions question:

Interviewer: "Why do you want to be a doctor?"
You predictably answer: "I feel like each of us owes something to those most in need. I enjoy helping those that are sick and knowing that I have made a difference in their life."
Interviewer: "F minus."

Now let's see what happens after hospital grizzling...
Interviewer: "Why do you want to be a doctor?"
You answer: "I used to think it was to help people, and that's part of it, but if that's all I wanted to do I'd be a nurse or a tech. I'm a smart person and I work well with stress and prefer it, and if I don't end up in a field where I am being pushed to the point of a panic attack, then I just don't want to do it. I am not going to end up as a computer being used as a doorstop. I had 13 months of that already and I just about lost my mind. I want to help people, but the best help I can give them is to go get some amazing training, study my ass off, and return a more capable physician. I'm not going to die happy having done anything less than that."

After it all I was a better applicant with better recommendations but I still didn't have the grades. Schools like to see trends. Straight Bs with straight As your last term is not a trend; it's the picture perfect of someone who could have gotten As the whole time but has horrible foresight. Every school was right to pass again. I prepared for that to happen and had a few applications out to Caribbean schools. They all accepted and so I went with the "Harvard of the Caribbean."

That' where I am now. I'm a second year student so Anatomy, Biochem, Histo, Embryo, Parasit, Bioethics, Jurisprudence, Immunology, Genetics, and a few others are all behind me. I plan on saying a little here and there about them as I move forward, but trying to tackle all of that right now is a sure-fire way to fail at the rest of life.

So that's our introduction. Nice to meet you.

Welcome to Grenada

2006-04-01T19:01:00.000-08:00

Welcome to Grenada.

First off, you probably do not know how lucky you are. The surprise for each new student is how beautiful Grenada is and how anyone could keep their sanity studying in any other place. What follows is a guide to your classes and a glimpse into what your life is going to be like in Grenada. A small disclaimer: I am a white American male twenty-something who had never left the US before coming to Grenada. It is very possible that certain aspects of Grenadian life specific to women are undereported. I apologize. Now let us get started.

ARRIVING

It is GrenEHda, not GrenAHda. Pronouncing it correctly is a big deal. Grenada was described to me as a third world country before I came and this will not be your experience. Your time on campus will be indistinguishable from any university in the US; your dorm life will be no different than your undergraduate experience. Everyone uses the bus or drives a car. You will have your Subway, your TCBY Treats, movie theaters, malls, grocery stores, hardware stores, school supplies, bars and clubs. You probably will not be able to find the laundry detergent you like or fresh milk, but these are small things. Anyone who says you will be "roughing it" is lying to you.

***That being said, a few people each year have a hard time adjusting. Some have dietary concerns (it is not hard to be a vegetarian; it is hard to be a vegan). Some get very homesick or cannot adjust to Grenada's culture. The pace here is very slow. ***

The very first mistake people make when traveling to Grenada is NOT taking a layover. Often times the airlines will overbook a connecting flight from Puerto Rico to Grenada and ask that passengers volunteer to take a later flight, often the next day. TAKE IT! You will be put up in a hotel, given miles for a flight in the future, and have a chance to enjoy another island carefree.

Many students have questions about how much their luggage can weigh. American Airlines (in my experience) will tell you to bring no more than two pieces of luggage weighing 50 lbs. each and one carry-on weighing no more than 40 lbs. The problem is that your connecting flight to Grenada may only allow ONE 50 lb. piece of checked luggage and will charge you an arm and a leg to bring the other, or flatly refuse. Call ahead and make absolutely certain with an airline official that your luggage will make it to Grenada, and then get that persons' phone number.

You will likely spend your first night in Grenada without your entire luggage. This is not a big deal. The airline will give you a number to call and you will have your luggage within a day or two. Try to come to the island early so you can take full advantage of Orientation week. It is nice to have that time for settling in, to speak nothing of all of the trips around the island that are provided.

Grenada’s weather has two settings: downpour and blindingly sunny, so come to the island wearing a rain jacket over a bathing suit. Grenada is likely hotter than you are used to. During those first few days, you will break a sweat from standing, lose weight, and drink water like breathing air. You will see students going to class wearing jeans and long sleeved shirts and wonder what is wrong with them. Just know that your body is getting used to the island; it takes about a month.

WHAT DOES IT LOOK LIKE?

It's amazing how a few photographs taken by students can add some perspective to the place. Go to Flickr and search for SGU. It says something that the students love the school enough to put all of this together themselves. My favortite albums are shot by Josh and Felix.

PHONE SECTION

No one gets a landline and you should not bring a cordless phone with you. So that means you are buying a cell phone. Since you are now going to travel from the mainland to Grenada and St. Vincent's (and possibly Prague) you probably want a phone that can work in all areas. For this, you need to buy a Quad-Band GSM phone. There are two main companies that offer GSM service in the USA. AT&T and Cingular are now merged into one company, and the second company is T-Mobile. So here's what you do:

1) buy a Quad-Band GSM phone from one of these companies
2) make sure that it is a pay-as-you-go phone with a SIM card
3) go to this website and pay for your phone to be unlocked

I'll explain all of that:

There are four major broadcasting systems used throughout the world. So a Quad-Band phone means that you'll never have to buy a new phone for travel. The SIM card is a chip that contains your phone number and your contacts. Put another way, it does not matter from what phone you call: if you put your SIM card in any phone the person you are calling will see that it is you. So if you buy a SIM Quad-Band phone at home, you will have a SIM card with your home's area code. When you come to Grenada, you will buy another SIM card with a Grenadian number. At this point, you can simply switch the SIM cards while you're one the islands and then switch them back when you return home. Taping them into your passport is a nice way to keep track of them when not in use.

The reason you have to "unlock" your phone is so that your T-Mobile phone (for example) will operate with a Digicel SIM card from Grenada (for example). Pay-as-you-go means that if you want to talk for ten minutes, you buy ten minutes. If you talk over that, the phone simply cuts off (after a warning of course). This means that you cannot possibly suffer overage charges and you don't get roped into a contract. And why do you have to pay to unlock your phone? Because T-mobile doesn't want you to buy there phone and then use it with an AT&T SIM card. T-mobile wants your money. Typically, these companies will unlock your phone for free if you've owned it for three months, but if you're reading this now that's a bit of late notice. So pay to have it unlocked from a separate code vendor and you should be set.

Some students make use of internet phones as well. There are several programs that allow you to make phone calls over the internet for pennies a minute to anywhere in the world. Skype, Netphone, and PCPhone are popular programs and only require a headset with microphone.

MONEY

For the next few years you will be using Eastern Caribbean currency, or ECs. The conversion rate is easy.

$100 = 260 EC. (exact ratio is 1/2.67, but we will keep the math easy and lose the pennies)
100 EC = $40.
Ex.
I have $25 in my pocket. 25 x 2 = 50. 25 x 0.6 = 15. 50 + 15 = 65 EC
A three ring binder is 35 EC. 35 x 4 = 150. 150 / 10 = $15 (binders ARE this expensive)

There are banks on the island and no need to ever use them. You can pull EC from your US account at any ATM on the island with a VISA/MasterCard debit card (sorry American Express and Discover). Some credit card companies charge a higher rate for foreign conversions, so check yours. The ATM charge is $1.50 and the conversion rate is standard. If you have a refund check coming to you, I suggest having the school send it home and having family/friends deposit it. You will need to leave deposit slips back home. Do not forget to leave deposit slips back home. However, if you want to pay for things by check, you will have to open an account with a local bank or have traveler's checks at the ready.

How much EC will you spend a day?

Depends. EC is pretty, looks like Monopoly money and you will spend it as such. Breakfast of eggs and toast is 7 EC, lunch is around 15 EC, and dinner can be up to 20 EC. That comes to 42 EC/$17 a day, eating out every meal. It sounds expensive but few people can pull off three meals a day. Most have one full meal and fill the rest with coffee and snacks. You will find your own happy middle. Remember that if you cook and buy your own groceries, you will save quite a bit.

If you drink anything other than water, you are in for a shock. Name brands like Coke, Starbucks and Arizona drinks cost three to four times what they do in the states. That being said, some people still manage to spend a great deal of money on water. Bottled water is sold everywhere on the island and is more expensive than beer. Some students buy a bottle every day. Others (and I recommend doing this) buy one bottle and refill it at dinking fountains on campus. All of the water on campus is filtered; this is not the case elsewhere on the island. I for one have had the same bottle for a month now and may have saved as much as one million dollars. Cigarettes are no more expensive than you are used to, but you should quit anyway.

WHAT WILL EACH DAY BE LIKE?

I get up every morning around 7am and check the class schedule. Typically only two courses are taught a day with each getting two hours of lecture time. On some days you will have Anatomy lab that can begin at 8 or 9am and lasts for three hours, or you have Histology lab at 8 or 10am that lasts for two hours. Lectures begin at 1pm each day and last till 5pm. You do not need to bring much to campus. I usually put my laptop, water bottle, two three ring binders and two textbooks into my backpack and grab the bus.

Eating on campus is not hard though students do complain about the selection. At the top of the hill (you will know it well) there are vendors selling fresh fruits and the Patels selling homemade Indian food. Halfway down campus is the Student’s Center which has two restaurants (Glover’s and Pearl’s) along with a convenience store. At the base of campus is the Sugar Shack. You will not go hungry.

Time before and after lecture is often spent in the library. The library has wireless internet and so should your computer (the “Computing at SGU” section of the SGU website does a good job of preparing you). During peak hours it can be difficult to get a strong connection (bringing an Ethernet cable is a bad move, as many of the plugs on campus work sporadically). The wireless network extends throughout campus into the lecture halls (you can follow lectures online or check email during breaks), across to the bus stop and down to the Student Area (where the gym and restaurants are located). Some students are able to get a connection in their rooms as well. If you live off campus in Grand Anse dorms there is a study room with a wireless connection. High-speed internet is available in off-campus apartments through a contract with Cable & Wireless.

SCHOOL CULTURE

During your first two weeks here you have carte blanche to introduce yourself to as many people as you wish. Your class will probably go out each night that first week and I recommend you go each time. The first week does not contain difficult material and you will not have another chance like it. After this grace period the classes pick up a bit, people fall into routines and your opportunities to meet every member of your class will start to drop off.

SGU operates by four-month-long terms. This tricks you into thinking that each term is a year long and that people in second, third and fourth term are somehow separated from you. This is of course nonsense. The uppertermers will have advice for you on every class and most of it should be ignored. Instead, find a good DES tutor, give yourself a few weeks, and then start making judgments on how to handle your course load. Everyone should go to the Department of Educational Services (DES) office and take a look at all of their handouts on studying, test-taking strategies, and review sessions. It is a goldmine of helpful information.

***I am aware of the irony that, as an uppertermer, I am writing this letter of advice.***

ISLAND CULTURE

English is the language spoken in Grenada. In the school guide, they describe it as a “slightly lilting Caribbean accent”. I disagree. Those Grenadians that work with the university, or in another position that requires constant exposure to tourists and students, are easy to understand. Those that have very little exposure to foreigners can be near unintelligible, but once you have an idea for what someone is trying to say, everything seems much clearer. It is not unlike listening to lyrics from a difficult song after you have already read them in the CD jacket.

If you have a healthy sense of humor, the stressful things about Grenada can be hilarious. First off, if you go to a restaurant and read the menu, do not kid yourself and think that what is on the menu is available. The menu is instead a list of things that were once available and may be available in the future. This is due either to a lack of ingredients, the staff is too busy to make your order, or the staff does not care to make your order. So order something else with a smile.

Second, if you order a drink at a US bar and it takes more than a few moments, it is often because the place is very busy and the bar is understaffed. If you order a drink in a Grenadian bar on a dead night when you are the only customer, it will take even longer. This is not because the bartender is trying to piss you off or ruin your whole day as some dramatics will say, it is instead because the island is a slow place and you need to get used to it. That Grenadian bartender could turn to you and ask, “What’s your hurry anyway?” Try to remember that there is no hurry and life will be a lot easier on you.

SPORTS

SGU has a healthy intramural sports program. Basketball and Football (soccer to some) are the major sports (bring cleats and guards, balls are provided). Hockey is also big (played on the basketball courts, sticks and nets provided). Rounding out the selection we have Ultimate Frisbee, Dance Classes, Yoga, and Dodgeball. I have yet to see a single person play tennis (I have not even seen courts) or cricket.

WET AND DRY SEASON

The wet season is very wet and runs from August to December. It can rain for days on end. If you bring an umbrella, make sure it is the type that opens to form a complete sphere around you, because the rain falls sideways. Honestly, go to a camping store and get a waterproof cover for your backpack, a light waterproof jacket and a shamie. You will be the envy of everyone. Another thing to consider is the mosquitoes. The breeding ground for mosquitoes is standing water, and there will be a lot of it. Invest in a mesh tent for your bed and screens for your windows (only applicable if living off campus). Want to know a fun trick? Instead of a mesh net, get a standing oscillating fan. If you go to sleep with it by your head, the mosquitos get sucked into the back of it and murdered. You get to wake up the next morning with a pile of them on the ground. Good times.

There is little rain in the dry season which runs from January till June. It is the best time to be on the island and enjoy everything that it has to offer. Go to the beach, learn to kite surf, bring your surf board, or rent a jet ski. Head to the capital and learn how to haggle in the market. Most of all, remember to get a tan so that people believe you when you say that you go to school on a tropical island.

GENERAL ADVICE

1. If you are buying a computer for school, make sure that it is light, portable and has a long-lasting battery.
2. Do not get a car your first term. You first term will be spent in campus housing and the bus schedule is more than adequate. A car is a luxury.
3. Sometimes the buses can get crowded. I suggest you say goodbye to personal space.
4. About a month into the term, Prof. Goodmurphy of the Anatomy Dept. will give a note-taking lecture that is invaluable and will change the way you and your class study. Do not miss it.
5. I have yet to use a single battery.
6. You can talk to prospective and current SGU students at ValueMD.com. Most posts receive a prompt reply.
7. If you get onto a Reggae bus and want to get out at your stop, tap the metal ceiling.

WHAT TO BRING

***This is not meant to be comprehensive by any means, but instead a few things that really would have helped me. ***

Binders are expensive on the island and worth the space in your luggage to bring a few. Anatomy gives you a binder so you should only need to bring three of your own. Multicolored highlighters are invaluable when reading biochemistry and hard to find on the island. I wish I had brought more. I also wish I had brought dry erase markers. Do not bring floppy disks and blank CDs, hardly anyone uses them. Instead BRING A FLASH DRIVE. Students share all of their files and useful programs with each other via flash drives or iPods. With exception to the iPod Mini and iPod Shuffle, iPods are actually much better than flash drives. They can play music, store 20+ Gigabytes of information in any form, and are far and away worth your investment.
As for your course books, the school supplies you with them the first week you are here. They are stored at the base of campus and are heavy. I would recommend picking them up in an empty piece of wheeled-luggage. Opinion varies in the upper terms as to which textbooks are useful and which never left their shrink wrap. Take advantage of your Footsteps Buddy and try to figure out which books will be most helpful for you. That said, there are some books that most people wish they had. Check the First-termer section.

First term classes

2006-04-01T18:59:00.000-08:00

Your first term classes:

ANATOMY
You are given a binder that contains, in order, every lecture for the term. This is useful for both following lecture and adding your own notes in the margin. You are given an Anatomy Atlas by Netter that contains oil paintings of every structure in the body with labels. You also receive Essential Clinical Anatomy by Moore which is the closest thing you will have to a text book. How helpful people found these texts is based more on individual learning styles than the actual content of the book. There are two books which nearly everyone found helpful that the campus bookstore does not always carry:

The Color Atlas of Anatomy by Rohen (ISBN# 0683304925)
An invaluable companion to the lab portion of your class, this book contains pictures of perfectly dissected cadavers to help in your ability to identify structures both in lab and on exams. This is best used in conjunction with your Netter Atlas.

Gross Anatomy by Chung (ISBN# 0683307274)
Part of the Board Review Series (BRS) collection, this book covers the material stressed on the USMLE Step 1, offers tables and clinical explanations that can save you hours in the library, and has hundreds of clinical questions that help you to prepare for your exams.

BIOCHEMISTRY
To date, the biochemistry department gives lecture handouts to the class two to three days before each specific lecture. These handouts reflect the stress and focus that each professor will give to the material. To fill in any gaps and round out your understanding, two textbooks are given. Lipincott’s Illustrated Biochemistry is an excellent textbook that closely follows the scope of the class. The other text, Mark’s Basic Medical Biochemistry, aims to tie everything that you will earn into clinical vignettes with patients like Al Martini the alcoholic.
You will kick yourself if you do not also purchase the Biochemistry BRS book (ISBN# 0683304917). It is written by, get this, Dr. Mark’s wife: Dr. Mark. She goes through her husband’s text, pulls the pertinent illustrations, and puts all of the information into a bare-bones linear style that makes learning the material laughably simple. Because of this, you could make the case that you do not need the full Marks text if you are going to buy the BRS book. Once again, the school bookstore does not always carry this title, so I suggest bringing it to the island.

HISTOLOGY
The Histology faculty has the best companion of all of your classes. It is so comprehensive as to be considered its own textbook. You will also have access to a free program called HistoTime. HistoTime consists of short histology lessons followed by hundreds of slides to help you recognize each specific tissue type. This program along with the companion is all that you need to do well in the course and walk away with an understanding of histology. That said, some students found the two textbooks required for the class (Color Atlas of Histology by Gartner and Basic Histology by Junqueira) to be helpful.

EMBRYOLOGY
The embryology course is changing faculty so I cannot guarantee that anything I am about to type is accurate. Embryology operates from a single textbook and a course companion. Some students complain that the course companion is hard to follow and is poorly written. While this is not altogether untrue, it is more accurate to say that Embryology is a difficult course of study in the first place and there are few things that could make it easy to follow and understand. One text that does a fair job of making the course manageable is the Embryology BRS book (ISBN #0683302728). Once again, the school bookstore may not carry this title, and I would suggest bringing it with you to the island.

BSCE 1

2006-04-01T13:34:00.000-08:00

This test is given a day or two after your last exam of 2nd term. It tests your retention up to that point with questions that are both external to the university (USMLE type) and internal (you've probably seen these questions on previous tests). It's a 200 question brute over 4 hours. Everyone feels like blowing this test off because a) failing it doesn't stop you from doing anything and b) passing it doesn't help you do anything.

I disagree. Your score on this exam ranks you against your class. You'll get a letter in the mail telling you your rank, your Z score, the mean and a breakdown of how you did in every section on external and internal questions. If you're serious about doing well on the USMLE, I don't know why you wouldn't take advantage of this test. Normally you have to pay Kaplan to tell you your weaknesses; the school is offering it for free. The school maintains that your rank is kept in house and does not make it onto your transcript. I haven't graduated yet so can't verify this. Students maintain that part of the decision-making when it comes to your hospital placement in 3rd and 4th year has to do with your rank, everything else being equal.

Moral of the story: doing well can't possibly hurt you, and doing poorly can't possibly help you. I for one was open to the possibilities, so tried to do my best. The best way you could possibly prepare (for the BSCE or USMLE) is to teach it. If you pulled a B or better in Anatomy, Biochem, Histo or Embryo then tutor the class. It takes two hours out of your week every week and it's a great review that your classmates aren't getting. And don't let fourth term scare you too much: my roommate and I team-taught Physio and Neuro and it was fine. We even had fun doing it.

So good luck and enjoy your summer.

Prague 2

2006-04-01T08:53:00.000-08:00

My last free weekend in Europe was a week ago and I had yet to travel anywhere. So the night before, I found a like-minded student, Adam, and we took off for the Brewery tour of the Czech Republic. We caught a bus to Pilzen, home of the only true Pilsner beer, Prazdroj. We arrived in this town, unable to speak Czech or find someone who mluveetee anglitsky (speaks english), so we decided to take random buses in random directions. We ended up taking a bus past an enourmous complex with PILSNER URQUELL written over and over on the wall followed on the end with a sign that said GAMBRINUS. Now, Gambrinus is a competing beer made in the Czech Republic. That, along with this bus stop being called "gambrinus", made us feel justified in riding further. We were such idiots.

After the Pilzen tour we caught a train for Ceske Budejovice, home of BUDVAR! We had about an hour until our bus into Cesky Krumlov was scheduled to leave, so we wandered a bit. I have to say that one of my favorite things about Europe is their town squares. Anytime a town devotes two square blocks to an open cobblestoned square with nothing in it but a central fountain, I am a fan.

A half hour later and we are in Cesky Krumlov, touted as one of the most beautiful cities in Europe. The place belongs in a snow globe complete with waterfall and wheel, aqeduct, palace, ornately decorated spire, and a lazy river that wraps around to define the borders of the city. Of course, I took no pictures.

The next morning we went back to Cesky Budejovice to take the brewery tour. Too bad it was Sunday. We made the best of it by sitting in the Budvar restaurant and drinking 5L of delicious Budvar each. I also managed to spend 1000 Krowns on a Budvar tie, tie clip, bottle openers, and a Budvar towel. I do like Budvar. I also have 6 Budvar coasters that tell the story of some demon that sneeks into the Brewery, tampers with the beer, and is then stoned with corn-on-the-cob.

And the winner of these priceless coasters and Budvar bottle opener? Uncle Neurophysiologist, for his advice on traveling in Europe:

"Look at your luggage and divide by 2; then look at your wallet and multiply by 2."

Returning to Prague, I have gone Euro. "Going Euro" is wearing the tight jeans, the tight shirts, the green sneakers, the button down shirt open with belly proudly leading on a hot day, the guy with no shirt in the middle of the classy bar, the girl and the guy making out so hard you think one is trying to eat the other (this drawing no stares). Going Euro happens in pockets instead of on a gradient. You don't have people that are half punk, half model, or half naked; everything is all out. It wasn't till the end of the trip that I realized how much I was ignoring, but Prague is a twilight zone of crazy.

In Prague, I have finally hit "survive" on the scale of Czech fluency. I can come and go, order and pay, ask and understand directions, and tell a Czech women that she is beautiful. But more than all of this, the ability to say "buzz off" in Czech without accent has been the most useful when dodging vendors and prostitutes on the tourist-choked streets.

Traveler's note: if a woman walks up to you asking for "sexy?" and you refuse, she will try to run after you and hug you. She IS NOT trying to change your mind; she is trying to pick your pocket. Channel Ron Burgandy, and you'll know what to do.

Landing back in the US was disorienting. First, everyone is speaking English while I'm still on Czech autopilot with my Dyekui's (thanks) and my Dobry Den's (hello). The faces in the airport are softer, without all the dramatic angles that hallmark the euros.

So that was it. My own advice for those traveling to Europe:

"Learn their language."

Cheers And Nastravi! (Nicedriveway)

Prague 1

2006-04-01T08:40:00.000-08:00

Where to begin. Having a bit of writer's block. I'm sitting off the balcony of my new room in a Hostel downtown. This is so much better than living in Kobylisy 8 with 7 other people in a room with four beds touching. I've been in Prague for seven days now. There are so many different types of faces and haircuts. The mullet is king, with every third person from the UK sporting one. The Scottish are terrifying. Every one of them looks like an extra from Braveheart that kept the costume. So scary. Nobody wears matching clothing, colour or decade.

Everything is different. Their toilet paper is thinner and has that recycled-paper look. I am still terrified of bedais (sp?). Men with capris are king; runner up is the tapered pant leg. The escalators are very steep and seems like the most popular place to stare at people. I haven't figured out if this is a staring society or if I'm getting the tourist treatment. Either way, I'm staring back.

It seems that only 3/4 of Prague is Czech, the rest ex-pat and vacationing. Opening up your head to all of the different languages ruins your ability to eavesdrop on your own, I've learned. I've learned about 50 czech words that I can't pronounce. Nerozemum = I don't know = most useful word. "krk"= throat. "Cheers!" sounds like "nice drive way" slurred. Beer is "pivo".

There are no ranch homes in Prague. You can buy a shirt that says "Czech me out!" but not one that says "Czech, please?" which disappoints me. Everywhere I walk has art. If not paintings on walls then reliefs over doorways or statues on state buildings. There is a statue of Lenin hanging from one arm four stories off the ground and out my window. There is a statue of Superman proudly face-planting into the ground.

My legs are oak dipped in steel. I'm averaging 8 miles a day on foot. There is something to look at or do every single step. There are so many restaurants that you marvel at how they can all stay in business. There just can't be that many hungry people. I have been living like a king, eating out every meal, sitting in beautiful restaurants that could fetch $100 plate prices back home but cost only $7. The dollar trades with the krown at 1/25. I feel like I am stealing from these people. There are so many places to eat that you are forced to have the appetizer, course and desert at three different locations with drinks at a fourth, fifth, ad infinitum.

I'm in Prague to study. A course through SGU places me on rounds with doctors from different fields, one per week. I lucked out with heart, brain and bone. Some poor saps got lungs, guts and kids. I have two more days of heart, where I get to watch a doctor push and pull a tube through someone's chest via a hole in their leg. We watch all of this on live x-ray monitors and ponder the weight of our full body lead vests. For the vest alone, I do not want to be a cardiologist.

Things to do:
1) walk across all seven bridges in Prague (maybe two people laugh at this)
2) buy uncle a gift for telling me about Budvar, the best thing since life itself
3) Get out of Prague for a while

Taking a nap and walking somewhere.

Go to Prague

2006-04-01T07:34:00.000-08:00

Go to Prague! As a January student, I went after my first term and knew nothing. Enjoyed the hell out of it. If you start in January and wait till the end of 4th term (2nd year) to go, you'll be squeezing the dates a little close together. I recommend as a freshman. If you're an August student, you get one crack at it: after 2nd term. This is probably the perfect time to go.

Get your friends together and rent a cheap apartment or stay in a 4-bed hostel suite. You chose your own level of grit. If you're a vegetarian, eat a face. If you're a recovering alcoholic, relapse. Prague is beer and meat and beautiful people and you shouldn't miss any of it.

Before you head over, go online and buy the DK Publishing Top 10 Eyewitness Guide to Prague. I lived by this book and it did not disappoint. Useful Czech phrases in the back. Also, don't ever call it "Czechoslovakia." The Czech Republic and Slovakia are quite separate now.

The set up of your selective is simple: Once a week you meet as a class with Dr. Stransky (the guy throwing this party) above Club N11. Besides being a big deal in Prague, he said one of my favorite things: "In life, it's good to be best, but it's better to be first." He owns the club N11 and will host a part there pretty early into the selective. As I remember, the first day you meet Dr. Stransky, learn about the program and what your rotations are going to be. Wear professional clothes. For guys this means shirt and tie. Do not be the guy with tennis shoes, an untucked shirt and a poorly-knotted tie. Ladies, wear comfortable shoes and a nice dress or skirt. Once you have your assignment, you meet in front of the N11 club with a bunch of other students, and someone working for Dr. Stransky takes your group onto the metro system for your destination. Remember it, because you'll have to do it yourself every day after. Your destination will change every week, so you'll repeat this process every Monday morning. Some people start rotations at 8:00am, some at 9:30. Everyone checks out by 5:00.

Each rotation at each hospital is different. For example, my Neuro rotation consisted of locking us in a room and letting a tape play (half the time), talking with Czech medical students so that they could practice their English (1/4th the time) and seeing a bunch of really interesting cases for the rest of it. If you understand 1 and 1/2 syndrome and the workings of nystagmus, you're golden. My Cardio rotation consisted of puting on a heavy-ass vest and standing in the room while the doctors snaked line up everyone's femoral artery into the heart. We watched all of it on angiogram. It was great, except for the vest and the revolving door nature of it all. My Orthopedic surgery rotation was my favorite. The doctors and nurses do not care what you do, so long as you don't hurt anybody. You change into their scrubs and gowns (their locker room) and just pick a surgery. Axilla surgery in room 1, hip replacement in room 2, and so on. I went to see a hip replacement and got blood all over me, which was AWESOME! Loved that rotation. At the end of the week you meet up above N11 with Dr. Stransky, see a patient, and talk about the week. Wash Rinse Repeat.

You're in Europe, the center of it, so you'll want to travel. I know people that made it out of Prague to go to Germany, Italy, what have you. It's hard though. You have to be at the hospitals on Monday and Friday. Once you factor in the time of transit to and from another country, you are really cutting things close to say nothing of a slow train or a broken one. To get the credit for the class, you have to have perfect attendance. That said, some of the doctors will sign your sheet for the week regardless of your attendance and I don't know of anyone that did the selective and didn't get credit. So who knows. Travel at your own peril I guess.

The weather in Prague swings. Bringing nothing but summer clothes with something nice for the hospital is not going to cut it. Bring a sweater, a jacket, something. Also, it rains in Prague. Don't be that wet guy without a raincoat.

Speaking of clothing, you should probably buy the greatest pair of shoes on the planet before getting on that plane. Everyone wonders why the people in Europe are so skinny? Not me. They walk everywhere, never stopping, always walking. So if you buy a pair of shoes that pinches your toe or drags on your heal ever so slightly, that'll be a gapping hole bleeding through your socks by the end of the third day. And since you're walking everywhere all the time, it will NEVER have a chance to heal. So just avoid that whole mess and buy yourself something nice.

The nightlife is great. Try to avoid the comfort of your two favorite clubs every night and see as much as you can. Joe's Cafe was a great one, and no trip to Prague can possibly be complete without a few trips to the Duplex. Enjoy the dancers and the air horn.

All in all, I hope you really enjoy Prague. Their subway system is larger than anything I've ever seen, and you'll have a great time getting lost even though their are only three subway lines. Every set of directions you'll ever give will be in terms of Tesco. It will take you a week to discover Andel. You'll buy a bottle of water, take one sip and spit it out, and forever after ask for "Voda, neperlive." (Voh-dah, nay-per-leh-veh) Make sure you're friends with someone who takes a lot of pictures; you'd be surprised how quickly you forget how great it was.

I wrote home when I was there, and I've included those posts. If you have any questions, please post them and I'll add where it's empty.

First Letter back home.
Last Weekend