The Final Cuts

Only one more week of gross anatomy lab, and it definitely feels like the last six miles of a marathon. Part of it is the daily monotony of two hours lecture, two hours lab; part is the tediousness of picking through tissues to find the needle in the haystack; part is the incessant need to memorize a vast amount of information. I believe the biggest reason for the struggle however is that we have come to the only part of Larry's body that has not yet been dissected (although when you look down at his body, a more appropriate word would be destroyed). Yes we have finally opened up his neck, face, and head.

The day we were to start on the face, our professors told us that this may be the hardest part of the dissection, and that it was OK to leave the room for a break. As I looked around the lab, it didn't appear to me that anyone was having a hard time. I think by now we have been so desensitized to the brutality of our dissection, that it has turned to mere scientific study. Even so, I still apologized to Larry as I picked up the scalpel and started to remove the skin from one side of his face while my lab mates worked on the other. I have gotten in the habit of talking to Larry throughout the dissections. A lot of apologizing and thanking him for his sacrifice, but also a lot of compliments regarding the wonder of his body.

After a day of studying the nerves, muscles, and salivary glands of the face, we moved on to the day in the lab that will forever stick in my mind, a day that I wished I could do the work without being there. Here is what our lab instructions told us to do that day:

"The skullcap (calvaria) will be removed for this lab. If the calvaria is still intact on your cadaver, make saw cuts as shown in Fig. 7.17. The first cut connects the superciliary ridges (anteriorly) with the external occipital protuberance (posteriorly). Apply MODERATE pressure and back out as soon as the saw clears the bone. Continue to circumnavigate the skull until reaching the start point. Use a chisel to pry the calvaria free. The dura may strongly adhere to the skull and resist removal of the calvaria. If so, carefully work a chisel between the dura and internal surface of the calvaria to free and remove it. Do not remove the wedge of occipital bone as instructed in Grant's Dissector. Examine the meninges and calveria. Only faculty or a MS IV student should remove the brain. There are many objectives today so move as quickly as possible."

Did your imagination create this scene? - A cacophony of buzzing saws, shouts of the students, and faculty over the incessant sawing, (which lasted for the whole lab since there aren't enough saws for each to have their own.) A strong bone burning smell accompanied the noise, and the baby blue masks we had over our mouths and nose, which were an improvement over not using one, did NOT stop the smell from entering your mouth and nose. So many of the students have said that they will NEVER EVER forget that smell. Remember the smell of the dentist tunneling through your tooth when you have a root canal, and then amplify that smell a hundred times.

The visual scene matched the surrealness created by the other senses. There is nothing casual or cautious about removing a person's skullcap. To suggest that the dura (the tissue that covers the brain) may be adhered to the skullcap is a grand understatement. It didn't take my lab mate very long to make the saw cuts, but it took at least a half an hour to pry the cap off with the chisel. I made the comment that Larry must not have wanted us to see inside his head. It was as if he was making his last effort to stop the invasiveness of our dissection. His final push of humanity - to attempt to keep that part of himself intact that is most associated with who he really was. The face is so personal, the eyes the window of the soul, and the brain the conductor of that symphony we call life. Sorry Larry, but once again, our metal tools eventually did what needed to be done. I had to look away as the skullcap was finally pulled off, the chisel successfully liberating the roof of his brain.

Balance, Part 2

I've had a lot of time, well that's an overstatement, a few free minutes here and there, to think about my last blog, and about what I do to try to maintain some sort of balance in my life. Even though I have already figured out that it's not really possible to have equal "balance" during this process.

This past weekend was an "exam weekend" which means that there was an exam on Monday and the whole weekend was spent studying as much as possible, both to learn new things from the previous week's lectures, as well as to review things we learned the week before. Right now in our gross anatomy course, the exams are every two or three weeks. Every two weeks is hard because then we only have one "free" weekend in between (which really isn't free, it just means we only study a few hours each day not 8 or 10). But then every three weeks is also hard, because we have a lot more to review, and many more concepts to know. There is so much to learn, and we never know what is going to be asked. A hundred questions on the written exam and only 50 questions on the practical - this despite the many hundreds of anatomical parts and concepts that can be asked. So of course, it's best to know as much as possible; hence, "exam weekends."

I have a fellow student friend who decided with his spouse that they wouldn't talk about anything having to do with medical school on Saturdays. This was a challenge for me on one particular Saturday when my husband Ronando and I, and this couple, went for a great hike up to Angel's rest in the Columbia River Gorge. (This was definitely not an exam weekend). I found myself quite challenged to find things to talk about that had nothing to do with medical school. What was there to say?

It was a good exercise for me, but I failed. I kept bringing things up that I remembered from lab, funny things that had happened, and insights into what we were learning in our clinical rotations. Many times I wanted to say something but then stopped, wanting to honor their "no medical talk on Saturdays" agreement. What a great way for a couple to force themselves to have balance in their lives while one is going through medical school! When we went home I asked Ronando if he felt like we needed to do something similar, and breathed a huge sigh of relief when he said no. If so, Saturday's would have been really quiet in my house. (I also felt a bit guilty about all the times in the last ten years that I asked him to talk about something other than work - now I get it).

But my friends' agreement to not talk medicine doesn't apply to "exam weekends". That's the time when all other normal expectations of life cease to matter. I get up early as possible (depends on how far behind I feel, anywhere from 6 to 8 am), and start studying at the kitchen table until I have to get up and eat something. I grab something quick, sit back down with the food in front of my notes, and keep reading, looking at photos, recalling all those new words that I will soon be tested on. It's the same for the whole weekend....and the morning before the exam. We then get a few hours off after the exam, to either go out and celebrate at a restaurant or bar with fellow students, to go home to pay attention to the family you ignored all weekend, or to just go home and pass out. If we're lucky we get to do all three! But then it's back to class 8 am the following morning, for a new blast of information.

So, we just finished our third exam, and even though the past weekend was therefore an "exam weekend" I did a few things for myself, to restore my social life a bit, and to recharge my battery. Friday night I went to a gathering of all my favorite women friends (my tribe as I call them). It was a potluck with lots of laughter, wine, and great food. My dear friend Tiffany gave me some advice that I have thought a lot about since then, advice that has helped me to find this slippery "balance". She lived with a medical school student for four years, and watched her roommate struggle with the demands of medical school, and trying to have balance in the process. Tiffany's words of wisdom were:

Valerie, don't fight it.

What she meant was for me to accept the demands of medical school and stop trying to resist what was necessary to become a doctor. It may not be in my best interest to live like this (how ironic, in learning to become advocates for healing, we go through a very unhealthy process, for many years...), but it is only temporary. Not as temporary as the painful two hour labor I had when Erinna came into the world, but four years is a small time when I look at the whole scope of my life. (I hope to live to at least 90). So even though it's painful, stressful, and hard at times, it is not going to last forever, so I may as well accept it!

Those pearls of wisdom woke me up like a shot of caffeine, and excited me just as much. Duh! I thought, you already know about all this: it's my attitude that will keep me alive during medical school. Not necessarily how many hours of sleep I get, or how many vitamins I take, or how much I exercise, but my attitude! So this got me thinking about the things I do to help me feel positive, and being with my favorite group of women definitely helped. The following day, after studying for 8 hours, I took a break to go to a movie with my husband. On Sunday I took a few hours off to go get a massage, the first one I have had in three months! It was delicious, and way way way overdue. I feel bad for the therapist who had to work on my knots....they were hard as stones.....I even rescheduled another massage for another month from now, to get back in the habit of taking better care of myself.

So, long story short, whether it's making time to talk about things other than medicine, to visit with friends and family, or to spoil ourselves with luxuries of movies and/or massages, it is possible to have a tiny bit of balance in medical school, and to enjoy the process. If I start complaining too much to any of you, please just remind me - Valerie, it's all about your attitude!! You can do it!! You are laboring through this in order to give birth to a new you - it is worth it!

PS. The photo is a shot from the top of Angel's Rest. Gorgeous huh?

Balance

During orientation many second year students as well as the faculty gave us first year "virgins" lots of advice about how to have balance while in medical school: How to keep your marriage or relationship strong (schedule dates), how to decrease stress (exercise or learn meditation), how to study effectively (figure out what type of learner you are - visual, auditory, tactile, and then do only what works). I only wish they had taught us how to stretch time. There are many days when I wish I could push a pause button, so that everything else stops, while I catch up - on studying, sleeping, eating, or even relaxing.

Let's do the math. There are 168 hours in each week. Let's see where all my hours go:

30 hours in Lecture/Lab/Clinic
30 hours Studying (at least, some suggest 1 hour for every hour in class, others suggest 2)

56 hours - Sleeping (I can't survive without my nightly 8 hours, a definite sign of my age....)

14 hours - Eating/Preparing Food (yummy, I love this part of my days...)

10 hours - Transportation to/from school (huffing and puffing on my bike)

7 hours - Showering/Hygiene (I've learned to take fast showers, and brush my teeth in a zip - forget about flossing every day - who has time for that?)

5 hours Cleaning/Dishes/Laundry/Grocery shopping/Paying those darn bills

5 hours Date night!! (gotta keep the man happy....)

7 hours mommy duties (being a taxi driver for my teenager, helping her with homework, taking her shopping for homecoming dance....etc...)

Grand total is 164....meaning I get about 4 hours every week to find balance!

So, after seven weeks in school I've finally realized what they all meant by balance, and it has nothing to do with equality, or with actually having a balanced life. It has to do with making the best of the situation at hand, laughing at yourself, and taking time off when you need to (like the day after an exam, when you can't even think straight there are so many words and concepts swimming around in your brain....). I am still learning, albeit slowly, how to have some lop sided "balance", and how to enjoy this ride.

Nevertheless, I still find that I'm becoming one dimensional. The terminology of medical school and the concepts we are learning are all pervasive - they leak into every conversation, every thought, even into my dreams. Two weeks ago, while in the midst of the abdomen dissection, I dreamt that my sister got stabbed in the gut. I was in the hospital ER with her, and after some scans of her abdomen, the doctors realized that the stabbing was actually a wonderful accident. The knife had miraculously missed the spleen, stomach, and large intestine, but had neatly cut off the tail of the pancreas which it turned out happened to be cancerous. So her life was saved!

Last week I dreamt that my daughter, despite eating and eating and eating, was only getting skinnier and skinnier. After a trip to the doctor, some tests and some scans, it was discovered that she had an ectopic (accessory) thyroid gland in her neck, which had failed to descend properly during embryological development, and so she had two functioning thyroid glands pumping out hormones that sped up her metabolism. Nothing some medication couldn't take care of!

I'm hopeless aren't I? I'm not sure how my husband and daughter can still stand to converse with me. The kitchen table is full of my books, as it has become my "desk". Sigh...... At these times I have to remember why I signed up for this in the first place - to take care of people. In another year I will be able to put all this studying behind me, and look forward to working 80 hours a week during clinical rotations. Who said I was sane? Again, it's not a sprint, but a four year marathon.

Temple of the Unknown

On the first day of orientation to gross anatomy six weeks ago, we were told that people looked just as different on the inside as they do on the outside. The last two weeks have proven that statement, as we dived into the abdominal cavity, revealing all the organs below the diapraghm.

First let me say that there is a ton of stuff packed into this space, and the individual organs are not in their own separate little compartments: they are all squished together, for reasons not only of space constraint, but also due to the embryological origins of the organs, and the blood vessels and nerves they are required to share. We first study these animated pictures in our book, where the stomach is one color, the pancreas another, and the different sections of the intestines are clearly delineated. We learn in lecture what blood vessels feed which organs, and what kind of path the vessels take on their journeys to the organs: short, long, or arduous. We try to understand the very complicated nerve webs that are spread out all over the organs and the blood vessels. (Very different from the arm where a nerve goes directly to a muscle and doesn't split into a large spider web of branches).

After lecture we prepare for the lab, change into our scrubs, and think about what the lab director told us the surgeons call the abdominal cavity: "The Temple of the Unknown." How can that be, the professor just neatly explained the organs and the relationships they have to one another, the blood vessels and the nerves. It can't be unknown. Ha Ha Ha.... From the very first cut past the abdominal muscles in our cadaver Larry, we are flummoxed because we cannot find the very first structure, which is supposed to lay over the small intestines, and according to all the pictures, is impossible to miss; it's a sheet of connective tissue called the greater omentum, a result of the complicated folding of internal tissues when the fetus is growing. We are convinced we don't have one, or think maybe it just got absorbed into the tissues of the small intestines.

After much digging around, (I'm convinced it has to be there), we finally find this greater omentum shoved way up near the diaphragm, hiding on top of the stomach. That's NOT where it's supposed to be. Then there's the issue of the cecum, a part of the large intestine that's supposed to sit way down by your pelvis, but on Larry is actually facing upwards, and sits in the middle of his abdomen. It's as if Larry was hung by his toes, and all his organs did not have the benefit of gravity keeping them in their "place." It doesn't stop there. Later we find an extra artery for the testis that doesn't belong. We determine it's not a vein or a nerve by following it from it's beginning to the end. Yup, it definitely goes through the spermatic cord along with the testicular artery, and it definitely comes off the right renal artery. Lucky Larry, he has double blood supply to his left testicle I say to the professor in the lab. Maybe not, he replies, more chances of loosing blood supply to the testis if it twists and turns inside the scrotal sac. Well at least it's not a fatal variation, as those tend to stop the growing fetus from even being born.

I move around the classroom and see that we are not the only ones struggling with finding all the objectives - digging and digging through an insane amount of connective tissue, layers over all the organs, layers in between the organs, and some more layers just for the heck of it. Variations abound, both natural and unnatural. The natural variations include extra arteries or veins, or the artery or vein coming off of the "wrong" spot. The organs are generally in the same area, but sometimes, as with Larry, there is variation there too. Of course it makes sense. There is lots of room for movement in there, and if there wasn't, a woman couldn't accommodate the growing baby inside her uterus (which of course hogs the whole abdominal cavity by the end of pregnancy). Not to mention when my stomach expands grotesquely after a great meal at my favorite restaurant after stuffing myself. (It would have to be an Italian restaurant - I have no self control when oi comes to pasta and red wine).

There are also unnatural variations that indicate disease processes. Several of the women have had hysterectomies, but thankfully there is one gorgeous uterus that I was able to palpate and hold so delicately (Life grows in this little muscular sac!). The cadaver next to us has a HUGE heart, about four times the size of Larry's heart, as their man died of congestive heart failure. Larry has a huge green gall bladder (hey, this is one part of the cadaver that does match the pictures in the book! But they probably won't tag that on the exam - too easy....). Other gall bladders are small, blending in the with the grayish tone of the other abdominal tissues. Larry has a large hard bladder, the result maybe of a prostrate condition, while others are small pliable sacs. A male cadaver in the room has an enlarged prostrate gland. I could go on and on, but the point is that variations are the norm, and that we can look at them as a source of wonder or a source of frustration (or both).

It's too early to tell but I am pretty sure that I don't want to be a general surgeon. If it takes me two hours to find an artery underneath the small intestines, how long would it take me to find something on a live patient, when all the tissues are red and bleeding? They did show us a few pictures in class of gall bladder operations, and as the surgeon is showing us the picture of a tied off cystic artery, vein, and duct, all I see is blood! That's what excites and challenges surgeons I guess. They have the knowledge base to understand the common expectations of location of the abdominal organs as well as their blood supply, along with the understanding that variations abound and must be looked for, in order to avoid snipping the wrong thing.

I look forward to the exam this afternoon. So I can put the abdomen behind me, and move on the the next set of objectives, to learn the anatomy of the legs and buttocks. Now doesn't that sound like more fun? Cheers!