The Heart Exposed

The site of a beating heart glistening and pumping is like no other site I have ever seen. The heart is simply amazing. It's more than just a four-chambered pump; it is well-designed machine that keeps our blood flowing to our muscles and lungs, ensuring we receive oxygen and nutrients to sustain ourselves.

But when the heart becomes damaged, we compromise our ability to circulate our blood to our tissues. This is a bad thing. And sometimes, we must intervene to repair this amazing machine.

When I walked into the OR with Dr. N, an anesthesiologist, I was awe-stricken. There was the heart sitting snugly in the middle of the chest, completely exposed.

To gain access to the heart, the chest literally had to be cracked along the sternum. The middle flaps of skin, fat, and muscle were pulled to the side, opened with large scoop-like metal instruments. The result was a square window, where the heart was exposed, and the surgeons were busily working to the tune of the ECG and Blood monitor beeps.

I gained an interesting vantage point; I stood from behind the blue drape that covers the patient's face. From above the blue, I could see the red blood and heart. And behind me, the monitors beeped, flashed numbers, showed squiggly lines--revealing the overall state of the heart through each stage of the surgery.

Watching the surgeons work around the heart took me back to anatomy. I can still remember the day in anatomy lab, when we each passed the scalpel around to cut the heart out of our cadever. When I held the heart in my hand, I could only think- "this was some one's heart- wow!"

Performing an invasive open heart surgery is long and complicated. The surgeon's were performing a mitral valve replacement. Essentially, the valve that separates the left atria from the left ventricles in our patent's heart was no longer functioning properly. If left untreated, a broken valve can lead to heart failure or severe cardiac complications. So, surgical intervention is necessary.

To place a new valve into the heart, the heart has to stop beating and must be kept cold (to protect the heart). While the heart stops beating, the blood is pumped out of the body through a cardiopulmonary bypass machine, which adds oxygen. So, the machine effectively acts as the heart, while the real heart is being repaired.

The surgeon's gloved hands skillfully sutured the new valve into the heart, as well as other areas of the heart that had be cut earlier in the procedure. And when the heart was ready, it had be be shocked to start pumping again.

I left the OR at 5 PM. By then, the surgery that had started earlier that morning was still underway. Metal wires were loosely placed through the two sides of the opened chest. The heart was being closely monitored, suction was used to remove any remaining blood, the last sutures were being placed, and the heart was pumping with full force.

**Image: "Open Heart Surgery." http://images.jupiterimages.com/common/detail/46/71/23127146.jpg

The Special Man

"We are looking for the special man," said the a female OB/GYN faculty member during today's Men in Women's Health panel. This "special man" is encouraged to join the OB/GYN field, where the number of males are dwindling.

Normally, Wednesday lunch is reserved for U-TEACH, an elective that takes us through the prenatal care and the birthing process. The scheduled In-Vitro Fertilization lecture was replaced with a Men in Women's Health panel, featuring an intern in OB/GYN in his first year of training and a faculty member that has spent the last 17 years at UCSF in OB/GYN.

Some of the issues that were discussed included the challenges, rewards, societal taboo associated with being a male in a field that focuses on women's health, and the downsides to being a male in the field.

One of the biggest challenges occurs when female patients will only see female providers (I place myself in this group). In that case, there is not much to do aside for apologizing or offering an female provider (if one is on hand).

Both panelists expressed a deep interest in their fields. They agreed that it is difficult to empathize with woman, having not experienced the contractions of labor or the pain of menstruation. But at the same time, they feel listening and paying attention to their patients can help make up for this deficit.

Some of the more interesting discussions revolved around what it's like for a male OB/GYN to focus his attention "down there" all the time and those conversations with significant others or friends that emerge, or the awkward silence that comes after telling others what one does for a living.

Also, panelists touched on the role of becoming sensitized to women. I suppose if you are a male and you see female patients all day, there is a possibility that the novelty of the female body wears off.

But that's where you learn to keep professional life separate from clinical life.

Overall, an interesting panel. Hopefully, the panelists were able to reach out to this "special man."

On a Scale of 1 to 10

On a scale of 1 to 10, how would you describe your pain? This is a question that gets to the heart of assessing the severity of pain. And yet, how accurately can we quantify pain given everyone has a different pain threshold?

Pain perception varies from person to person, and can be affected by different conditions.

Patients with fibromyalgia experience a lower threshold of pain (they are more sensitive). There are certain trigger points where pain is most pronounced; patients will experience muscle, joint pain, and fatigue.

Today in preceptorship, we confronted the issue of pain management and fibromyalgia.

***

It was a nice sunny day walking to Dr. D's office. While walking, I pulled out my camera and snapped some photographs of the neighborhood. Emily and I performed intake and took patient histories today. Going into the room, we had little knowledge about what brought each patient to clinic. And we walked out, fully aware of not only the present medical illness, but each patients entire medical history.

***

In talking with patients, the issue of pain management came up over and over again. Patients living in chronic pain have to be concerned about the pain management, which is often complicated and requires medication that have side-effects, such as constipation and fatigue. Also, what happens when patients become dependent (or addicted) to their relief source?

"You do not hunt a rabbit with a cannon," said Dr. D.

Dr. D extended this analogy to pain management; you do not overuse opiates or pain killers when managing pain.

Image: Image from the Neighborhood (off Filmore Street)
Dr. D has a good point--but I wonder about how to adequately help patients in pain without making them dependent on medication. And we must remember pain sensation is subjective, with a different scale for each individual.

Jumping!

Yeah...not much going on here.

Giving Thanks!

If I had to choose a favorite Holiday, it would definitely be Thanksgiving! This holiday is shrouded in a great deal of historical controversy and I will not delve into any of that. But I appreciate the simplicity and beauty that comes from two of my favorite things: food, family, and giving thanks (OK, that is three things).

Tradition is big part of Thanksgiving. For most, it's all about turkey, stuffing, cranberry sauce, and pumpkin pie. In my family, we have our own traditions and they do not include any of the above. We had baked chicken instead of turkey and a fruit tart instead of pumpkin pie. We decided on the fruit tart to celebrate my Dad's Birthday, which happens to also fall on Thanksgiving.

Bottom line: I love Thanksgiving. I love food. I love family. And there is a lot to be thankful for.

I am thankful for my amazing family: my parents, siblings, and extended family (and my cat- Chitty, pronounced Chit-tee). These are individuals, who have made so many sacrifices for me. Their unconditional love, support, and concern is always with me. They make my life complete. I cannot begin to thank them for everything they do (and have done) for me.

I am thankful for my friends. My friends bring joy to my life, making me happy, spending time with, and being there for me. I hope to cultivate these life-long friendships.

I am thankful for my health, one of the biggest blessings of all. Every day I wake up, excited for another day. I am thankful for food, water, and shelter--basic amenities that are so essential that are sadly denied to individuals in the third world and in nations ravaged by war and instability.

I am thankful for being able to live my dream: medicine. As a medical student, every day is about learning about how to effectively serve my future patients and their families. It such an honor to learn the language of medicine and the stories of my patients, while standing alongside my amazing classmates. I am excited for the next steps and challenges that await me on my ongoing journey in medicine, as I continue navigating the complex mechanisms of human disease, fragility of human life, and as I understand what speciality I should pursue.

I am thankful for being a student at UCSF and for the endless opportunities to explore, learn, and serve.

I am thankful for San Francisco, the city with a soul. There is so much that I love about the city: the people, the diversity, the beauty, the individuality, the distinctive culture, the food. Experiencing the city is so wonderful and refreshing.

I am thankful for my SLR Digital Cannon Rebel camera (it allows me to see the beauty in world through a lens and produce timeless images). I am thankful for my running shoes, my bike, the gym, Golden Gate Park.

I am thankful for you (reader)- for entering my inner world. It makes writing worth every word, when I know there is someone out there, who reads and is interested in learning about my life. Having an audience brings meaning to my writing. And for that I am grateful.

There is so much more to be thankful for; I could go on and on. But I'll stop here.

Happy Thanksgiving!

***Image: Dad's B-day Fruit-Tart (our pumpkin pie equivalent)

Break!

It's break time! From noon yesterday until Monday morning at 8 AM, we have our first official break. Thanksgiving!

Before making the journey back home, I spent my afternoon at Jane's prenatal appointment. The waiting room was filled with expecting moms and the temperature was as cold as ever. It's the 25th week. Jane is doing well; her mother and father will be visiting soon. She is anxious to see her family.

The babies are moving a lot and being monitored very closely on ultrasound. On the black screen, we could make out the little hands of Baby A (the boy), who was either punching or attempting to wave. We could see Baby B's (the girl) heart pounding. On average, the babies should be kicking at least 5 times an hour.

Jane will also have her blood checked for gestational diabetes, a condition that some pregnant woman develop during pregnancy. According to the American Diabetes Association, approximately 4% of pregnant woman will develop this condition, which can result in hyperglycemia (high blood sugar).

Normally, sugar is broken down by a insulin, a hormone secreted by the pancreas. But in pregnancy, the growing placenta secretes hormones that prevent insulin from working. As a result, higher blood sugar pools in the blood, which move into the placenta and can cause birth defects and complications in pregnancy.

***

I will see Jane next week at her next ultrasound appointment. We will continue to watch the babies as they grow and exchange family stories.

For more information on Gestational Diabetes: http://www.diabetes.org/gestational-diabetes.jsp

Image: "Gestational Diabetes." http://www.pennhealth.com/health_info/diabetes2/images/19724.jpg

The Power of Touch

Come on. Admit it. You are afraid of something. Even Superman was not invincible--there was krypnonite.

We all have our fears--everything from darkness, snakes, rejection, falling, etc. Being afraid is being human.

I would say I am afraid of being alone and exams, but that is only half-true. I think it's more the anticipation that gets me. Tests are just a necessary evil. Speaking of which, our first cardiovascular midterm ended and we move right along...

After the exam, I decided to spend time in the Women's Health World alongside Dr. S, my mentor. I spent my summer conducting research on HPV and cervical cancer in her lab. She is renowned for her work on HPV, including her research into the effectiveness of newly developed HPV Vaccine.

Being reunited took me back to the summer days of experiments--PCR, running gels, Immunohistochemisty, and staining slides. It's hard to believe how much time has passed and how different my life has become (so far from land of test tubes and pipettes).

I was with Dr. S during two straightforward gynecological procedures in the OR.

What I remember most (aside from using a laser to remove warts) is the power of touch, when a patient must face her fear.

Before surgery, a peripheral intravenous access must be obtained so that anesthesia and fluids can be administered during the surgery directly into the circulation. But to establish this access, a needle must be injected into a peripheral vein, such as the vein on your hand or arm.

For most patients, this is an uncomfortable procedure. But for some, needles can be so scary that they physiologically induce something called the vasovagal response that can lead to hypotension (lower blood pressure) and syncope (fainting epidose).

The second patient has struggled with facing needles. And today was no exception. To help her, I offered the only thing I could- my hand. As the needle was inserted, I held her hand and maintained direct eye contact with her, while initiating a conversation to keep her mind preoccupied. There was discomfort, but she stayed with us. After the needle was in, we covered the needle with a nice blue sleeve and she was ready.

As Dr. S said, "Sometimes mind overcomes matter."

After surgery, we visited her in recovery. I will never forget her words.

"Thanks for holding my hand and talking to me, it really helped."

Sometimes, the smallest things can have the most powerful effects.

***

Image: "Hands." http://artfiles.art.com/images/-/Christine-Ellis/Loving-Hands-Photographic-Print-C12153830.jpeg

I can't get the Heart off my Mind

Just thought I'd share what's going through my mind...it's more of an obsession with knowing the heart with an exam in less than 24 hrs...

Image: http://library.med.utah.edu/kw/pharm/hyper_heart1.html

Lub Dub S3

If only the heart was this simple. In fact, the heart looks like nothing this. I have no idea why the heart is always represented as such. Any anatomist (or first year medical student) could identify all the innacuracies. Let's not go there...

The real heart looks something like this. But the veins are not color coded (there is no blue; just shades of red).

I can not get the heart out of my mind. I know the heart is the universal sign of love, but it has occupied my brain for other reasons. Our cardiovascular midterm is on Monday.

So, we're all getting to know the heart very well, no love here- just endless amounts of facts and understanding this incredibly complex organ.

Images:

"Heart."http://www.annerpino.com/2003/heart.jpg

"The real heart." http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1097.jpg

When the War Comes Home

Consider this ethical question: would you be willing to kill one violent/evil individual at the expense of 3 innocent individuals? If no, do you think it's justifiable to send someone in your stead to take care of this business?

Aidan Delgado, a Conscientious Objector of the War in Iraq, posed this ethical question to an audience of medical students, residents, physicians, staff, and community members when he opened his discussion "When the War Comes Home," hosted by the UCSF Iraq Action Group. In particular, he highlighted the concept of "collateral damage" and moral casualities of war.

According to Delgado, "Collateral damage has no meaning to us. It is faceless." He believes that the public will attribute collateral damage to the numbers on the CNN ticker without thinking of individuals, such "Ahmed or Mohammed."

Having been stationed at Abu Ghraib prison, what he calls the "Baghdad Correctional facility," Delgado reflected on his experiences, providing graphic images of the causalities of war--mutilated children, injuries of war, defaced bodies, prisoner brutality--images that captured the dehumanizing effect of war.

Delgado, who is profient in Arabic and grew up in Egypt, enlisted in the army on September 11th. He joined before the attack, feeling vindication, which later transformed into moral opposition.

"My small part was like a tiny cog in a machine that allowed the war to take place," he said. As he became exposed to the reality of war--the cruelty and horrific human cost and the dehumanization of fellow comrades, he was determined to make a decision, drawing from his Buddhist religion. He could either be a Sunday Morning Buddhist (practice Buddhism once a week) or Live Buddhism in his daily life.

He decided to turn in his rifle and become a Conscientious Objector of the War. Despite the initial ostracizing and hostility, he has remained opposed to the war and shares his experiences with groups all over the nation.

"War has such a profound, corrupting effect. There is no family that has been untouched in Iraq." He compares the ongoing war to the the mythical hydra: cutting one snake causes two more to sprout. Like the hydra, the insurgency continues to grow in opposition to the US attack.

According to Delgado, we can not kill our way to peace. And an American presence will not promote stability, due to a prevalent Anti-American rhetoric in a country where families have lost loved ones to the war.

Delgado admits that there are 2 sides to the coin: Americans are helping civilians with building schools and hospitals. But the violence and cruelty of war dominates, negatively impacting and blackening the American image.

Delgado compares the war to a barbed arrow. We can either pull the arrow out, or let the wound bleed until there is no more blood left. There is no way to undo the damages of war and bring back all the lives that have been lost, or reverse the prisoner brutality at Abu Ghraib. He believes it is time to pull the arrow out--withdraw and bring our troops home. And despite the challenges, he believes that there still is hope.

In opposing the war, he does not oppose the troops. Instead, he questions our rationale for entering a war that is morally wrong. He believes that the image of a soldier should be changed into that of a peacekeeper.

Delgado compared the war to a game of chess and we can not blame the pawns or the rook, when the chess player controls the moves. But he believes we must keep the war on our moral radar and remember about our mounting karmic debt.

****

Image: Event Flyer in Med-Sci Lobby

Aidan's Biography (provided by Iraq Action Group Flyer): "Aidan Delgado will speak about his experiences in applying for Conscientious Objector status while serving as a soldier in Iraq and at Abu Ghraib prison. He will show slides depicting some of the violence and brutality that pervaded the Army and discuss the morality of war from a Buddhist perspective. His intends to bring home the reality of war to citizens here in the U.S., so that they can make an informed moral decision about whether to consent to this war. Aidan Delgado is a peace activist, member of Iraq Veterans Against the War, and the author of "The Sutras of Abu Ghraib: Notes from a Conscientious Objector."