33.5 Degrees of Hope

Last week, I visited UCSF's Neuro-Intensive Care Nursery. I had the opportunity to learn more about the Nursery and photograph the nursery for a feature article for the UCSF School of Medicine's website. Visiting the nursery with my camera was truly a unique opportunity. My essay and some photographs are included below. It can also be viewed at the following site: http://medschool.ucsf.edu/news/features/patient_care/20081222_NICN.aspx


Teddy bear wallpaper lines the top of the room. Large machines beep, and tubes are covering most of the crib that holds Baby E. Her small body is covered in plastic. Her face is just visible underneath the breathing tube. Her head is covered with white gauze, holding a series of green and red wires in place, which are connected to an EEG machine to monitor her brain wave activity. A camera records her movements. Despite the loud noises of the Neuro-Intensive Care Nursery (NICN), her eyes remain closed as if she were completely oblivious to her critical state of health.

The UCSF Neuro-Intensive Care Nursery (NICN) is located on the 15th floor of Moffitt Hospital. The front windows show a panoramic view of the city, from the ocean to downtown. Family members mill in and out of the nursery.

Dr. Tom Shimotake, Co-Director of the UCSF Neuro-Intensive Care Nursery, had given me a tour and introduced me to Baby E. Baby E had been transferred from another hospital and admitted to the NICN the previous night. Though being born full-term, she was in critical condition.

Since opening in April of 2008, the NICN has seen referrals of this type quadruple. UCSF's NICN represents one of the first nurseries in the United States that specializes in treating infants who have experienced brain damage during birth because of asphyxia, which prevents oxygen flow to a newborn’s brain and can lead to irreversible injury of neurons.

The NICN integrates multiple technological and treatment modalities along with clinical trials, to optimize the monitoring and care of critically ill infants who are at high risk for developing cerebral palsy, mental retardation and other cognitive problems later in life.



We were joined by Deidre Jarrell, Baby E's nurse, who has been with the NICN since its inception. She has specialized training to care for infants like Baby E who have suffered brain damage at birth. She works 12-hour shifts, attends to Baby E and provides updates to family members, who can call anytime for information about the baby's status.

As we surround Baby E's crib, the infant would periodically stir or kick her tiny feet. Bags of fluid were perched above her, dripping clear liquid into her system. She was sedated, and a machine was breathing for her. She was lying on top of a blue blanket that was set to maintain her temperature close to 33.5 degrees Celsius.

Baby E is receiving cooling therapy, which involves inducing a hypothermic state for 72 hours. According to Dr. Shimotake, the cooling therapy prevents further brain injury in babies born in a hypoxic (oxygen-deprived) state. Cooling needs to be started within the first six hours of birth after asphyxiation to have a benefit, and this therapy is only for babies born full-term.

After 72 hours of the cooling therapy, Baby E's body temperature will be slowly increased (0.5 degrees Celsius per hour) to her normal temperature. Her brain will then be imaged with an MRI to assess the primary injury, including the location and severity, to help develop a prognosis and determine the next steps in her long-term treatment.


Infants will spend an average of 10-14 days in the NICN. While in the NICN, they receive specialized care from a multidisciplinary team that includes neonatologists, pediatric neurologists, epileptologists, specialized NICN nurses, neuroradiologists and occupational and physical therapists. Social services, another integral component of the NICN services, are available to families and healthcare providers to help cope with the emotional stress that comes with caring for critically ill infants.

Dr. Shimotake believes families play a central role in making decisions, and healthcare providers must remain sensitive and open to each family's desires. "We deal with very sick babies here, so we participate in some of the most emotionally intense moments in these families' lives. In addition to specialized care for the babies, we provide important information to families that they may need to make difficult decisions. We don't make decisions alone."

In working with critically ill infants, healthcare providers are sometimes faced with the delicate balance between prolonging life and making decisions about palliative care. Some infants arrive at the NICN and are monitored, treated and discharged. Some will develop long-term neurological abnormalities, requiring lifelong specialized care. And some will have life support withdrawn due to an irreversible brain injury that shows no sign of recovery.

Those infants who are discharged from the NICN will visit their regular pediatrician and undergo ongoing physical therapy and follow-up with physicians at the high-risk neonatology clinic. They and their parents meet with a number of specialists, including neonatologists, developmental psychologists, physical therapists and nutritionists.

***
As I watch Baby E, I wonder about her prognosis and life after the NICN. Will she be among the patients that gets life support withdrawn? Or will she regain her strength and go home to her family? How is her family coping, not being able to hold their baby, who is covered in tubes and connected to so many machines? How are they processing the endless amount medical information presented by Baby E's medical team?

Vacation

One week of vacation has gone by in a blink of an eye.

I spent the first few days in San Francisco taking care of business, tying some loose ends. I finally made my way to Union Square last week for some aimless shopping. And then left SF.

I arrived at my parent's house on Thursday. Since arriving, I've been spending time with my family, catching up and eating some delicious traditional Indian meals. In between, I have braved the chilling cold to fit some runs in my day. It's cold, but so much flatter in Davis, a welcome change from the hills of SF (although I do miss the views). I have been reintroduced to a concept three complete meals and eight hours of sleep. This is the life.

To sum up- vacation has been relaxing so far. I'm working on writing something insightful. For now, I'll enjoying the simplicity of life and the smells of fresh food without thinking too much.

The Endless "To do" List

M3 Mania has ended. I turned in my final today, proceeded to take the lung and prostate practical (almost mechanically). By now, tests have become a part of norm. We learn how to program our minds to ingest voluminous amounts of information in such short periods of time to answer question after question (and then we repeat the process). It's a well-oiled process for the most part. Except one big problem- retention. In the end, after an exam, you feel numb, knowing well that most of the information you meticulously hand wrote on multiple pieces of paper to committed to short term memory, will dissipate to a foregone memory. The reality of medical school.

When I walked out, I felt relieved but also unsure about what to do with myself. I have become so school-centric; my long to-do lists revolves around getting through material for small group or lecture, planning electives, preparing MSP sessions, etc. I can now attend to the growing list of things, some school-related (odds and ends), as well as a plethora of life things, namely shopping and social engagements.

The end of M3, which included cancer, blood disorders (leukemia, lymphoma and anemias) and epidemiology takes us to Christmas break. I am looking forward to spending time with my family. Outside of the cancer block, I was able to spend time in the pediatric intensive care unit in Oakland, working with a diverse spectrum of critically ill patients. I also had the pleasure and pure enjoyment of teaching cardiac anatomy and ischemic heart disease to first years during MSP sessions.

When we return from break sometime in January (not sure what date exactly) we start our last preclinical block (Life Cycle). A couple of weeks ago, our course directors sat us down and gave us that unwelcome talk about the "B" word, we have tried so hard to suppress. THE BOARDS have come upon us, infiltrating our subconscious and libraries with board review books. Not exactly sure when studying begins, just know it's going to be long, hard and epic. Overall, I'm apathetic to the exam. More concerned with getting it over with to move on to a "watershed moment" in our educational training- the wards. Hopefully, in the process I'll relearn all those important facts that have escaped.

Although we have become programmed professional information memorizes and test takers, I still can not believe how fast time has gone by. It was a year ago, when I finished my cardio exam and was preparing for clinical interlude. Now, I'm moving into uncharted study territory.

For now, I'll bask in being done. And with time, after some distraction (time to go shopping), I might actually look at the oh so endless "to do" list. I am hoping to reflect and write to process second year, looking at how I have changed and how far I have come.

From my year of medical school, I have learned that no matter how many things you have to do, you must always remember that you also have to live your life.

World AIDS Today

1 in 10 San Franciscans living with AIDS does not receive primary care.

December 1st marks World AIDS Day, a day to raise awareness about the AIDS epidemic. Today was the 20th anniversary. AIDS sprung to our attention in the 1980's as a mysterious disease affecting predominately gay men. With the emergence of the disease came discrimination and mistreatment due to lack of understanding. Today, we know more about the AIDS and the virus (HIV) that is transmitted by blood, sex and breastfeeding, which can lead to the development of AIDS. And over the last two decades, we have seen the face of AIDS (it affects everyone).

Over 60 million people have been infected with HIV, a number that continues to grow. And the death toll continues to rises.

There is so much that has to be done to understand the virus, decrease transmission, fund treatment and support those living and dying with HIV and AIDS.



Today, we gathered together, each donning sign with a statistic. With our signs and red ribbons, we made our way to Parnassus Avenue (right in front of the main hospital), where we stood in solidarity, remembering those who have lost the fight and those that are continuing the battle the disease each day.

Chugging Gatorade

The weather has transformed into the cold, bitter gray that is winter. For the last couple of days, I've been under the weather, chugging Gatorade and lemon-lime flavored carbonated beverages, while curled up in a ball on the sofa, staring aimlessly at the coagulation cascade page of the syllabus.

It definitely does not help when you know a little about the differential for fever, fatigue, headache and myalgias. You just start thinking way too much about which bug it could be.

Thankfully, I'm feeling much better in time for Thanksgiving. By tomorrow, hopefully, I can eat my fill of home cooked food.

We'll see...

M3 Mania I

After today, we should now be able to complete a head to toe physical exam (theoretically). In our last patient education/physical exam session, we learned about how to complete a clinical breast exam, which involves a visual inspection (from four different views), lymph node palpation (in the axilla and near the collar bone) and the breast exam. Like the female and male pelvic exams, we were taught by patient educators who demonstrated the exams on themselves before walking us through each step of the exam, as well as teaching us important points about establishing rapport.

The breast exam is not just about the breast as we think of structures contained in the bra. In performing the breast exam, it helps to think of an imaginary rectangle drawn around the breast, starting from under the arm going up to the clavicle along the sternum and down just below the breast. Using a light, medium and deep palpation with the pads of our fingers, we feel the fatty and glandular tissue of the breast as we move our fingers in a cork-screw pattern vertically on the tissue.

As I performed the exam, I said aloud "light, medium and deep" to help coordinate my actions. To completed a thorough exam, when you are learning, it takes some time (more than 2 minutes). And it's always hard to make sense of what you are feeling; everything feels kinda of lumpy and bumpy. "Like a bunch of grapes," said our patient educator. And every patients tissue will obviously feel different.

In explaining the exam to our patients, our patient educator made a good point- we perform a thorough exam to establish a baseline, which will serve to us detect any change (the other "C" word), not just for cancer.

In completing my first breast exam, I know it will take lots of practice to master the fine art of detecting subtle tissue changes that may come in the form of pea-sized lumps. "One day, you may be saving lives," our educator said as we closed the session. Maybe.

Other than performing a clinical breast exam on one of the nicest and warmest days in November, I spent my Sunday indoors preparing for our first M3 exam. We transitioned from Infectious diseases to the mechanisms, methods and malignancies block, formerly known as the cancer, bench to bedside, block.

Preparing for this exam has been partly a walk down undergraduate memory lane, taking me back to the days of when I majored in genetics and studied cancer as part of my research. Revisiting the genetic basis of cancer and the molecular biology of tumorigenesis has been interesting, especially as we learn the connection and see how the science relates to the clinical picture of a disease that impacts so many people.

Having been personally affected by cancer, it is sometimes difficult to read about the studies that predict five-year survival of patients on certain drugs, or learn about how cancer can recur or metastasize to other organs. It's hard to focus on the biology of a disease, when you can't help but see a face of someone you love who has suffered from the disease. And at the same time, it is promising to hear about the advances made in treatment and understanding the disease.

All in all, this has been a somber block. And Studying for the tomorrow's exam has been especially difficult (story of my medical school life).
M3 Mania continues...homestretch!

What a Week!

This has been one amazingly busy week! Perhaps, one of the most epic weeks of medical school and history.

Tuesday was unbelievable. With the swipe of a magic black marker, I cast my vote early in the morning, braving the cold and lines. I proudly wore my "I voted" sticker all day, knowing that we may make history.

During pediatric preceptorship, I completed my first pediatric neuro exam on a one and half year old girl, who was fast asleep when I arrived. She did not like tracking my penlight, but she did like the fluffy teddy bear. Later, we listened to a presentation from a pediatric cardiac thoracic surgeon, who spoke about how to repair congenital deformities involved with babies born with large vessel switching.

We did make history on Tuesday! I was brought to tears, as I watched the election results unfold. After 8 PM, when it was announced we had elected Barack Obama, I was elated. I am excited this welcome change.

Wednesday we made medical school history with our annual class play- MDTV, which was remarkable. I don't think I have ever laughed that hard. The mix of music videos, live skits, performances and video skits (that featured classmates, faculty members and first years), was one awesome production. I made an appearance in a couple of the video skits, namely a video titled "Girls gone Mild." (I really hope it does not end up on youtube).

I was also part of the final dance number, which was set to the song "Bye Bye Bye," with rewritten lyrics. After rehearsing (for what seemed like forever), we finally performed to a crowd of screaming medical students and faculty members (and the stage lights are super bright). It was quite an experience...I would love to take a dance class (if only I had the time).

After the end of the dance, we stayed on stage for the Final song number- "Seasons of Gloves." It was so heartwarming be in the company of my classmates as we sung (a slideshow of our first year flashed behind us as we swayed). The final hurrah that is our class play was extremely memorable. Now the curse of topping our class play gets passed to the Class of 2012, who must now hit the drawing board to devise an even better play.

Thursday was another long day. I taught my first cardiac MSP session. We moved from the anatomy labs to the chalk boards in the classroom. I taught cardiac anatomy, one of my favorite topics. I truly hear the the heart (seriously).



Friday is here. And the weekend, which means catch-up time and learning the language of cancer. I'll be spending time with family this weekend, so we'll see how much gets done.

Cheers to an unforgettable week!
***

Bye Bye Bye - Lyrics by Ning


We're done with this tonight
It's time to turn on the lights
We hope you thought it was tight
Hey baby, come on
We worked on this endlessly
So that we could help you see
That you're not in this med school business alone


We know that you can't take no more
It ain't no lie
You laughed so hard your abs are sore
Baby, bye bye bye


Right now everything's so new
But before you now it you're an MS2
It seems crazy, but it ain't no lie
Baby, bye bye bye


We know that this med school's tough
You probably feel like you already had enough
But you'll all make it and it ain't no lie
Baby bye bye bye


Just hit you with the truth
Life's better as an MS 2
I'll give you some good reasons baby, come on
No more anatomy
Just Life Cycle and I3
We study, take the boards and then we're gone
Goodbye to the Essential Core
It all flew by
We'll see what third year has in store
Baby, bye bye bye


All of us were just like you
But we all made it, now we're MS2s
You'll all make it and it ain't no lie
Baby, bye bye bye


We know that this med school's tough
Learning how to use a blood pressure cuff
You'll all make it and it ain't no lie
Baby bye bye bye

Being DNA Polymerase

One genetic degree and two years of medical school later, I am amazed at what I have become. For Halloween, I probably selected one the most nerdy costumes (of all time). I was DNA Polymerase, the enzyme that replicates DNA.

My costume was complete with a homemade sign, spandex, loop earings, a replication fork necklace and an oversized shirt that read "How do you express yourself?"

It was funny watching people reading my sign and trying to figure it all out. My costume only works on the UCSF campus or around my science/medical school friends. So, I did have the perfect daytime and nighttime outfit.

I know...look what I have become- pretty scary!



Happy Halloween!!!

The Little Beating Hearts

I listened to a baby's heart for the first time today. The bell of my stethoscope was humongous on the baby's small chest. I could hear the pounding and rapid heart rate of our six-month year old patient. I could also hear an amplified inspiratory stridor, every time he took a deep breath in. As I listened to the heart, the beeping monitors over his head registered his heart rate, pulse, and oxygen saturation.

Later on, I got to see a beating heart of a baby that had just undergone cardiac surgery to repair a congenital abnormality that required reconstructing the vasculature of the heart. The little heart was pounding.

Today was our first day of pediatric preceptorship. I spent my day at the Children's Hospital in Oakland in the Pediatric Intensive Care Unit. Within the PICU, there was a number of young patients of all ages with a spectrum of medical conditions. In our shift, we saw everything from newborns with congenital abnormalities to young children with lung problems to teenage victims of trauma.

"Pediatrics is about observation and integration," our preceptor said. For this reason, we first observe our patients before moving towards any examination. We started by standing at the foot of our first baby's crib and watched him breathe, observing him and noting any abnormal physical findings.

The 23-bed PICU was a bustling area. Some patients were asleep or sedated, while others were being attended to by family members or health care workers. In a corner bed, family members read letters aloud to a young girl, who was unresponsive.

The site of children in hospital beds attached to tubes and monitors was surreal. I am not used to seeing children in the hospital and it was difficult to take the entire site in. Listening to the cries of patients and watching family members circle over their loved one's bed was heart wrenching. I can not even imagine how families cope with critically ill children.

Today's shift in the PICU was an eye-opening experience. I look forward to our return visits to the PICU.

Farewell Bugz

The fog settled in yesterday, blanketing the city; I got a glimpse of the speckles of the city lights, as I made by my way home late at night after a day of filling every crevice of my brain with details relating to the microorganisms that invade our world and our bodies, everything from bacteria to viruses to fungi to protozoa.

Friday marked the last day of I3 (the microbiology block). In lab, we got to see real life Schistosomes, organisms that are transmitted by snails and can penetrate through the skin of hosts and reek havoc in the veins of the bladder, colon or liver. (Another reason why you should be careful in fresh water). So, needless to say- we kept our fingers to ourselves while observing the cercaria (worm-like creatures) that were swarming in the water.

With our final tomorrow, I am amazed at how six weeks of infectious diseases has impacted my differential diagnosis for fever, chills, diarrhea and rash. I went from thinking about a handful of things to now making an endless list of possibilities. Such an expansion will invariably contract, so I've been warned by my seasoned resident friends.

For now, I bask in the joy of knowing that I have learned about so many rare diseases and organisms (some pretty crazy bugs), which I may or may not encounter in the years to come. They do exist out there. And I am little more obsessive about washing my hands and properly preparing my food.



Aside from extending my intellectual bounds as far as they can, like a rubber band that has been stretched to capacity, I am really exhausted and looking forward to the end of infectious diseases. We'll finally get a much-needed interblock break from all the bug madness.

Cheers to the end (it's almost here!)

Diagnosis

With a diagnosis of sinusitis in a 43 year old man complaining about congestion and coughing, we completed our adult preceptorship. We walked into our preceptor's office just a year ago.

While spending time in an Allergist's office, I have seen my share of inflamed noses, heard all sorts of wheezes in lungs of patients with asthma, seen all shades of prurulent discharge on the back of patient's mouths and observed the prednisone injections. And I have met real patients from the community, so different from the standardized patients we are accustomed to seeing in the clinical skills center.

I have learned to take a full history and perform a directed physical exam (mostly for an upper respiratory infection). I have become versed in the language of immunology as it relates to asthma and allergies. I know to check for nystagmus anytime I suspect a eustachian tube obstruction.

I appreciate the time my preceptor took to teach me and for allowing me to enter his office.

Making a final diagnosis was a great culmination of preceptorship and a nice preview of what awaits us in the spring, when we venture into the wards.

From here, we move to working with "little people," as we soon start our pediatrics preceptorship. I am looking forward to the adventures that await us in the next phase of our medical training.

The 10 P's of Success

A Department of Surgery chair, from a well-known medical school, shared some pearls with a crowd of 250 eager medical students at the American College of Surgeons Clinical Congress, Division of Education Medical Student Program, which is being held in San Francisco this year.

She listed the 10 P's of Success in Leadership in Academic Medicine.
1. Plan
2. Be Prepared
3. Pay Attention
4. Look at the Process
5. Be Persistent
6. Demonstrate Power
7. Find a Partner
8. Be Pleasant
9. Pace yourself
10. Don't take it Personally

She asked the audience members to add any additional P's. I volunteered the following- finding inner peace, especially in difficult situations and as a general rule to balance one's life.

Other P's audience members provided included the following:
-Pride
-Politics
-Passion
-Proactive
-Productive
-Appreciation
-Potluck?
-Perseverance
-Prayer
-Patience
-Pure
-Possibilities
-Play
-Perform (under pressure)
-Push (your personal boundaries)

I'll try to attend more of the ACS sessions to learn more about a field that had continuously intrigued me and remains an evolving interest.

Exam 1

We clustered in front of Cole Hall, with our baked and store-bought goods in hand. Once everyone appeared, we slowly made our way to the lecture hall. I entered first, carrying a plate of home-made brownies (triple chocolate) and placed the plate in the front of the lecture hall. After me, another 30 or so classmates streamed down the stairs of the lecture hall with their desserts.

It was so heartwarming to bake for the first year medical students. Today was their first exam of medical school, a milestone for many students. I remember how nervous and anxious we all were, huddled in front of Cole Hall. And how refreshing it was to see the former second years bring baked goods for us.

I made sure to schedule time for baking yesterday. Lately, my life has become before PDA and schedule-centric (story of my life). I usually get the store-bought desserts, but I wanted to put some effort in this little project. I know how hard the first years have been working in anticipation for this exam; I have been helping teach anatomy during MSP and answering questions (content and non-content based).

In the end, I hope everyone does not get too caught up in the score on the exam. And just remember that it's "pass now or pass later," the mantra I recite to myself a lot more now.

With the exam almost done for most of the first years, I wanted to wish them all a hearty congratulations on completing your first exam--one of many more to come!

No Surprises

"No Surprises." That was the lesson of today's lesson.

Last week was the female pelvic exam and today was the male pelvic exam. Our educator, reminded us that the the pelvic exam is not as simple as asking someone to "stick out their tongue." Like the female pelvic exam, there are many parts to the exam that take us to an entirely new physical exam territory.

Our educator emphasized the importance of remaining "nonjudgmental," when we start dealing with real patients from the real world, including real human sexual behaviors that may not seem normal to us. We gain to learn from our patients and in doing so, we must pay attention to our facial expressions, verbal and body language.

There were three main parts to the exam: the breast exam, pelvic exam and rectal exam.

Although breast cancer is most common in women, men can develop breast cancer. For this reason, it is important to perform the breast exam and teach patients to perform self-exams. The cases of breast cancer in males generally is more severe, because cancer often goes undetected.

The pelvic exam was not nearly as complicated as the female pelvic exam (there was no metal instruments). Most of the exam was external, involving visual inspection and palpation, with the exception of the classic hernia exam (turn your head and cough test). As our educator walked us through the motions, he explained how to be sensitive to our patients, including the golden rule of "no surprises," to stress the importance of open communication and clear explanations.

The last part of the exam is the dreaded rectal exam (uncomfortable for the patient and the examiner). Our educators had some great tips to help patients relax (because no one really relaxes if you tell them to "relax.") Lubrication and deep breathing exercises combined with Kegels may do the trick to help patients relax (or to help the examiner relax, at least).

As I mentally prepared myself for the rectal exam (specifically thinking about where my finger was to go), I realized how we have learned to palpate and navigate every corner of the body, including orifices, such as the anus. Using a wind-shield motion, I could feel the surface of the prostate gland and with a 360 degree rotation, I could feel the rectal wall (the anatomy can only be appreciated your finger has made it's way far enough up, in case your are interested in knowing).

The last exam will be the breast exam. After that, I will have learned the full head-to-toe physical.

We come a long way. It will be interesting when we start performing full physical exams on our patients. Hopefully, we'll remember the lessons our educators have taught us and have too many surprises.

Remember to Exhale

Before inserting a speculum (a metallic instrument that helps better view the cervix) into any vagina, we always ask our patients to take a deep breath. The rule can be generalized to when we insert anything into the vagina. And on exhalation the speculum goes in. As I asked my patient to take a deep breath, my patient was watching me, giving me similar instructions.

"Eisha, breathe." Oh yeah, I forgot that part. Don't forget to exhale. In between handling the duck bill of the speculum, inserting the metallic monstrosity into the vaginal opening, pushing it through and looking into the metal mouth while opening the mouth to identify the cervix (which just pops out from nowhere), I must have forgotten to exhale (I certainly hope my face was not showing my apprehension).

Today was another milestone in my medical school life- completing my first female pelvic exam. It was thorough and complete (with a fair share of awkwardness and difficulty), including everything from examining the external and internal genitalia to the speculum exam to the rectovaginal exam.

It's a unique exam because your fingers are not only palpating and exploring new territories (I never knew my finger could go in that deep), they are also "seeing" for you. Although I have seen the Netter images of the uterus, vagina and pelvic muscles and dissected the pelvic viscera- I felt somewhat blind as I made my way around the fornices and uterus. It felt odd, relying solely on a finger in a small space to reveal the anatomy.

Our patient knows her body extremely well. With a hand mirror, she was able to verbally guide me through the exam, capable of engaging me in a conversation even while I nervously tried to readjust my finger to better palpate her uterus or cervix. She is an educator, who feels "empowered" to assist budding physicians and health care providers. She instructed us to "let go of any anxiety."

She prides herself in effectively training health care providers to perform the pelvic exam and develop rapport with patients. She was fantastic; I was impressed by her calming presence and extensive knowledge of her own anatomy.

"Everything you say or do must have intention," she said. The pelvic exam is like no other because your patient probably feels the most uncomfortable and vulnerable. (Any woman that has had to put her legs in stir-ups for the pelvic exam can attest to the discomfort and unpleasantness of the exam). For this reason, we must explain each step (especially since our patient can not see what we are doing down there) and we must be careful about what we say, and only say things that have a purpose in our exam. Word choice is pivotal. "Normal and healthy" are probably better descriptors than "perfect or beautiful."

Like anything else, practice makes perfect. I know it will take me a couple of exams before I can really understand the exam and know that I am, in fact, palpating an ovary and not just the vaginal wall (believe me, it's difficult the first time, at least for me). And I'll remember to exhale...

Bugz, Bugz, and More Bugz

I have this urge to wash my hands every 10 minutes. I will never look at a rash the same way. I am frightened by any chief complaint that begins with fever, or stomach pains.

Over the past 11 days, I have been seen my differential diagnosis for fever expand. And do not get me started on diarrhea, a subject in itself.

We transitioned from immunology to microbiology/infectious diseases. Put simply, microbiology involves learning the autobiographies of criminal bacteria, which each have different shapes, life cycles, toxins and targets. And then we have to follow the crazy bugs through their disease rampages, as they tear through our tissues and evade our immune surveillance, causing inflammation and infections that are each so different and yet so similar in terms of clinical presentation.

Classic case: 25 y/o presents with fever, chills, muscle pains and sore throat.
(this could be 1 of like 20 diseases, and this is a conservative estimate).

The number of diseases caused by bacterial pathogens is impressive. Actually, it's amazing how we are surrounded by bacteria and how they colonize our tissues, and we somehow seem to be in some sort of equilibrium (until we get sick or eat something funny).

The funny thing about this block is the names of the bugs we have to know; they are unreal and unnatural. Bacteriologists fail to follow the rules of spelling we learned in elementary school. It's interesting how some scientists decide to name a bug after themselves. For example, Alexandre Yersin, a physician from the Pasteur Institute discovered the pathogen causing the plague and named it "Yersinia Pestis," after himself. Now, the black death will be connected to his last name. I do not know if I would want to attach my name to something like that.

I did learn that as a child we were already playing homage to Yersin and the black death, as we sang "Ring around the rosies," (refers to the red flea bite), "pocket full of posies" (people during the medieval times kept spices and herbs in their pockets to deodorize the smell of the dead bodies), "ashes, ashes, ashes- we all fall down" (victims coughed up dried blood and people suffering from the black death, would fall down to their death). I wonder who decides which nursery rhymes children learn.

The number of bugs we must learn for our Midterm tomorrow is magnanimous, like the volume of watery diarrhea expelled with cholera infection. On Friday, our professor (after teaching us the 10th bug at the end of the lecture hour), said something to the effect of: "This is the time that you are all probably hating medical school." (He was spot on; it is somewhat overwhelming to learn this much detail about bugs).

Although there is a massive amount of information to be internalized, I do find infectious diseases to be somewhat intriguing. All these years of hearing about pneumonia or meningitis or lyme disease and not know really know anything. Now, I know how serious these diseases are with an understanding of the microbiology of these bugs that have developed intricate methods to evade our immune systems. I am even more paranoid about washing my hands now.

With a fat pile of stack cards to be reviewed, I best be off to mastering these bugs rather than being phased by the microbial word that surrounds us.

Anatomy Lessons

I can not get the smell out of my hands. Even after changing out of my scrubs, I still could smell the familiar scent of anatomy lab on me. And I have taken a shower and still can detect the odor of latex-presservative on my hands.

It was not so long ago, when I got my whiff of this odor when I first ventured onto the thirteenth floor for my first foray into anatomy.

The first years had their first anatomy class today. A day that seems like it was in another lifetime for me. Today, I was teaching abdominal muscles and viscera during my first MSP session.

It's funny how quick it comes back. I had not seen the abdominal muscles since last year and before I knew it, I was teaching the three layers, focusing on a method to teach that avoids simply memorizing. In this case, it involved a demonstration of grabbing in your pocket to grab a piece of candy (direction of external oblique), place the candy in your mouth (direction of internal oblique) and rubbing your stomach (direction of transversus abdominis). There was also an abdominal workout.

Last year at this time, I struggled to unzip the body bag and reflect the skin back to visualize the muscles and abdominal viscera. Today, I was actually teaching the muscles, maneuvering the viscera and muscles almost like a robot. Now, I can really appreciate the anatomy without having to worry about any test.

I guess I have come some way. It was a pleasure to teach the new students. I hope they can handle my unusual mannerisms, bad jokes and hyperactive personality (I swear teaching brings out these qualities and I am not normally like this). It is just so much fun to share my joy of medicine with others.

There are somethings that do not change- the smell of anatomy remains (still).

Cheers to a year of MSP!

Superhero Day

Yesterday, I was madly searching through my closet and drawers for anything remotely resembling a superhero costume. I am so amazed at how normal my wardrobe is. Aside from lots of exotic scarfs and tunics, there was nothing that really caught my attention. So, I settled for spandex (bike pants), an over sized DNA shirt that read "How do you express yourself," a red and yellow pokadot scarf, socks emblazoned with red hot chili peppers, a big black beaded necklace and a mask of confidence.

I was to be "Super Eisha," for our MSP debut for the first years. As a way to introduce the teaching program to the first years, the group of 16 MSPs leaders decided to dress up in super hero outfits (mostly colorful spandex).

And with our cue, "Don't fear, MSP will come to the rescue," we streamed into the first year's lecture hall, making our grand entrance by running and screaming to the front, where we were introduced. Now, that's what you call making a first impression.

Although I was going for the superhero look, I ended up looking more like I was off some 1980's exercise video, with my hair tied back to the side and in my spandex. One word- hideous! At least, I was in the company of 15 other MSP teachers, who exuded excitement to teach the first years, starting with anatomy and later teaching organs physiology.

Later today, one of our MSP advisors, commended us. He wrote, "It was really fun to watch you guys do your thing. I'd sign up again in a heartbeat! And don't feel bad that they sat there looking puzzled/scared while you ran around screaming, you all did the same thing when we did our announcement last year. It's been highly studied
and the evidence is overwhelming that this is a limbic cortex associated
instinctual reaction to the sudden appearance of rockstar superheroes
(p<.001)

Well done!" I guess that's a nice way to put it.

After my superhero arrival, I walked out in my hero outfit (to some awkward stares) en route to my apartment, where I had to change into another costume- a black powersuit. Now, I know what Superman must feel (it is so hard to run around in spandex and then change). I rushed and quickly changed grabbed my black stilettos and ran to the Curricular Showcase, where I was presenting a poster outlining my summer curricular project.

For two hours, I stood and explained my project to faculty members and students. After the 10th time, I thought- I should have recorded myself speaking and had everyone click a button to hear the description.

It's been a long day. If only I had real superhero powers (right now, I'd pick the power of learning all the bugs we are supposed to have learned by now). I may not that power, but I do have spandex and I sure to know how to rock a 1980's workout outfit like no other!

Class of 2012 White Coat

Last year around this time, I stood up in a freshly ironed white coat in the company of 150 medical school classmates and recited the Oath of Louis Lasagna, a modern version of the Hippocratic Oath. Today, I was reminded that I will be repeating that same oath in less than three years during graduation as I listened to the new first year medical students recite the same oath.

The sea of white coats spoke in unison. As they recited, I looked through my lens, snapping photographs. Frame by frame, I was reminded of a time not so long ago, when I just arrived on the UCSF campus, bright eyed and blissfully unaware.

The Dean welcomed the Class of 2012 in the presence of the faculty members, whose names and faces I have come to know. Addressing the new students and their families, he reminded students that when you put the white coat on, you are "accepting a sacred responsibility to your patients."

When I think back to my White Coat Ceremony, I remember the excitement and joy of being coated in a pristine white coat. In my three inch black stilettos, I hobbled on the stage (in my mind I was nervous and anxious and kept telling myself not to trip and to imagine that the stage was like a runway). I must have been one of the harder students to coat (the added height must have made it hard to slip the coat on). My mind was racing, but when my name was called, I made my way to get my coat from my mentor, in what seemed like a blink of an eye.

According to the President of the UCSF Alumni Association, the first white coat was worn in a medical settings 150 years. Surgeons were the first to wear the white coat, a symbol of cleanliness and sterility. Community doctors soon followed, picking up the coat and taking up the aseptic look, in an initial attempt to differentiate the physicians from the quacks, in what he described as a "massive publicity stunt."

The white coat ceremony is certainly one of the milestones in my medical school career. Everyone was all smiles; and it was contagious to be around such a happy group of students and family members.

I had privilege of taking photographs, as the "unofficial photographer." As such, I was was given a second-row seat (right behind the faculty members) and the liberty to roam around the floor. That's one of the best things about being a photographer, you make your canvas and gain unique vantage points and access. I saw the ceremony partially through my camera lens and through my experience being the recipient of a white coat. I was vicariously reliving the experience in my mind (some parts as clear as day, others hazy, and others completely forgotten).

It was simply a pleasure to be a part of an event that is so special and central to the incoming students and their families.



As I watched the new medical students receive their coats, it was amazing to see the happiness and pride in their faces, a mix of disbelief, relief, and something to the effect of "I have no idea about what I'm getting myself into, but I've heard this medicine thing is supposed to be good." The families were both proud and excited. And it was a pleasure to watch the families congratulate their medical student and pose in the post-ceremony photographs.

It was not so long ago, when I was standing in those photographs smiling widely, unaware about what would happen next. A year later, I'm still smiling.

New medical students, welcome to the family of short white coats! Best of luck (the medical school honeymoon has ended and the real fun is just about to begin).

***

Oath of Louis Lasagna
"I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help."

Whirlwind of Immunology

"You guys and medical students all over the country have had your blood drawn right now," said our professor yesterday. She was referring to how medical students are typically used as experimental subjects in studying the relationship between stress and the release of cortisol, a steroid that affects our immune system. Apparently, medical students the day before a big exam represent one of the best stress model.
And increased stress (chronically) leads to suppressing the immune system, which explains why you are more likely to get sick right before the exam.

Do we really get that stressed over exams? Apparently we do (and research studies have shown that). While I was studying, I looked up at the T cell-mediated toxicity poster on my wall and realized I actually now knew what was going on. I know, I'm a big nerd for actually posting a poster about T cells on my wall. It just fills white space (I'm being serious).

I'm feeling more relieved right now.

After 11 days of immunology, we finally took our Final at 1 PM. For the last few days, I have been mastering (or trying to master) the language of nerd and watching my cortisol levels rise.

CD4, CD8, IL-2, IFN-gamma, IL-12, cytokines, MHC, APC, DC, CTL, CMI (just a few of the codes that have been drilled into my brain).

The immune system is complicated but one of the most intricately designed systems that mediates our body's defense to pathogens in a series of cell to cell interactions that is as elegant as a waltz dance. I have a deeper appreciation for a microscopic process that can selectively recognize and destroy a foreign particle, while discriminating between the gazillion self cells. With this foundation, I can view pathology with a new lens. If only I had microscopic glasses to actually see the intricate world of immune cells.

For the first time in medical school, we were given a written exam (no multiple choice). When I got the exam today, and saw the white spaces, I was reminded of the days of undergraduate education, when you studied to regurgitate. The strategy back for questions you were unsure about was to write everything that came to your mind and hope it made sense the poor grader. Today, I was really avoiding that. And writing a book causes my hand to hurt.

It seems like we move in light speed in second year.
Onward to bugs- Microbiology starts tomorrow!

Cheers to finishing Immunology!

Adopting a Sib

This weekend, the incoming first years spent their weekend at the annual Medical School Camping Trip; the classic combination of team-building games, introductions, socializing and alcohol. My camping trip feels like it was in another lifetime. So, odd- you go from thinking about your classmates to being around them in the wilderness. The camping trip was one of my earliest memories of my classmates and medical school, reminding me it is somewhat reminiscent of high school in some respects.

The first year medical students will make their debut on Tuesday; crawling out of the summer vacation hide-outs and congregating on campus for a week of Orientation activities. Honestly, the first week is about repeatedly congratulating the medical students (over and over again) and explaining what medical school is about plus a plethora of socializing activities. And the week culminates with the White Coat Ceremony, one of the most memorable experiences in my life.

As second years, we have the opportunity to adopt little siblings. I selected my little sibling and finally contacted her (and got a response). I am so excited to meet her and share some pearls of wisdom.

When I officially adopted my sib, I was already thinking about the first order of business- a gift. I ended up getting her a pocket handbook to help her with doctoring, a pink pen light and a candy bar. I hope she likes it (or finds the gifts useful). I slipped her gift in her mailbox today.

When I meet her, I hope I can fulfill my siblings duties.

Year 2 has begun

"To learn pelvic anatomy, you will need to pull your compact mirrors out," said our anatomy professor during the pelvic anatomy session. She was presenting a series of images of the male and female genitalia to prepare us for performing the pelvic exam. We will be expected to complete the pelvic exam in the next few weeks. (Stay tuned...)

Her words were met with some chuckles and whispers from the audience. We knew she was joking. But she was serious about encouraging each of us to study our own pelvic anatomy using a mirror.

When she mentioned this, I was reminded of the episode of "Sex and the City," when Charlotte struggled to use a mirror to visualize her own anatomy down there.

It hit me today. We are in the second year. We are really getting closer to becoming doctors. OK, I know this realization is a little overdue. Somewhere in between the immunology whirlwind and the pelvic anatomy overview, I realized how the expectations are so much higher.

Even in our learning, we have gone from patient cases to case conferences and journal club presentations. And we are moving toward performing a a full physical exam, by learning the pelvic exam.

The standardized patient interviews are not as straightforward as the first year interviews that followed a relatively predictable outline. The interviews are more complicated with patients that actually do not listen to you (sounds familiar to anyone you may know?), reminiscent of the real patients we will be encountering outside the walls of our classrooms, in the community and hospitals. Our doctoring facilitator echoed this sentiment, telling us that "the interviews in the second year are so much harder."

Although there are some curve balls being thrown at us, I suppose it's time. In a way, it's refreshing to push ourselves a little further. Even if that means being yelled at by our standardized patient interviewer or if it means that we will be soon sticking our fingers in some of the most unthinkable places.

The second year is upon us and quickly unraveling...

"B" Word

On the second day of the second year of medical school, they finally dropped the "B" word.

During lunch, the School of Medicine and class representatives hosted the Med II Welcome Back Program. We were promised lunch, so most of the class remained after our Lymphocyte Development and Immunodeficiencies lecture. The falafel did not arrive right away. So, we all sat and waited while being regaled with announcements and updates.

We learned about what others did over the summer, including research (my group), traveling and non-medical activities. In addition to a plethora of announcements from the class reps and fellow classmates, we were introduced to the Student & Curricular Affairs staff (new and old faces) and a road map for the second year

During the second year overview, our faculty discussed our clerkship preparation and finally dropped the "B" word. You guessed it- the "Boards." Our second year will culminate with this monstrosity of an exam, or as one faculty member puts it "a big quiz," a rite of passage to third year, if you will.

To date, our faculty have done a great job safeguarding us from any needless board anxiety (mum has been the word). But now the floodgates have opened and we have been made aware.

In all honesty, most of us are fully aware of this exam on the horizon. I've pushed into the back of my mind. But now it's slowly making its way forward, akin to a cold, harsh reality that we will soon face.

Oh well. The "B" word is out and there is no taking that one word back.

The Return

The sun finally shined. As I walking up to my friend's house to watch a movie, the warmth made me happy and a bit anxious; I was just thinking how our schedules would become so much busier.

It's hard to believe that we return to the start of our second year of medical school in less than 12 hours. Where did the summer go? It evaporated in the absence of SF heat.

8 weeks have elapsed. Looking back, my vacation was a pseudo-vacation; I spent most of the weeks in lab, pipetting and conducting basic science research. Long hours in lab. The days were regimented, a mix of experiments, reading dense articles and completing work for my curricular project. The evenings were more exciting and included any combination of the following: trips to the gym, running in the the park, swimming indoors, watching TV, eating dinner with friends, hanging out my brothers, reading and writing.

All in all, it was relaxing coming home and not having to study, or prepare for small group.

The carefree days are over. I have started the unthinkable (the reading for tomorrow's lecture) about the immune system. A focused examination of innate immune response is a bit futile, because my mind is elsewhere, pondering how we can be returning back to school so quickly (a blink of an eye).

It will be nice to be reunited with classmates and learn about what others did this summer. Other than that, I'm dreading the 8 AM lectures and studying. Oh well, the day was coming the moment we walked out of our BMB finals. It's time to move on.

Cheers to a great summer and here's to hoping for another promising year of medical school. Wish me luck!

23.

There is something mysterious about the number of 23. In fact, the term "23 Enigma" has been coined to explain that 23 (and any permutation of 23 or any number related to 23) is somehow linked to all incidents and events. Very Interesting.

For some believers, 23 somehow may be the key to explaining how and why things happen. If good things happen, 23 is lucky. However, if bad things happen, 23 is unlucky. Ultimately, it comes down to the interpreter.

I'm struggling to decide what I should make of 23, two numbers- the previous one less than the latter. I suppose I would have more insight if I knew what to expect from my 23rd year of life. For now, I'm going to keep an open mind and hope 23 brings as much joy as 22.

My mother called me yesterday around 10 PM.
"Happy Birthday, Eisha. I'm calling you the day before your birthday because your were born after midnight." She said.



August 21st- my birthday. Growing up, I always had a bitter-sweet birthday; I was celebrating my birth along with the end of summer vacation. Somethings really do not change. I'm celebrating my 23rd birthday four days before the arrival of the storm that is the second year of medical school. I bought myself a gift: the immunology syllabus.

I celebrated a birthday earlier with some of my friends. The birthday cake was one of the best gifts ever. One of my best friends actually took the time to make the choclate ganash cake from scratch.

Looking back, I have to say I was blessed. 22 was a great year. I am thankful to God, my amazing parents, four brothers and sister, friends, classmates, teachers, blog readers and patients for truly enriching the texture of my life by providing me with everything from love to support to knowledge to patience to reassurance. I am here because you all have placed so much faith in me, giving me that energy that puts a smile on my face in the morning and allows me to move forward each step of the way.

22 was a year of so much change; the year I began my first year of medical school. A year of new relationships and friendships. A year filled with learning the art and science of medicine and becoming a part of something so great. A year of new discoveries and realizations.

22 was a year of many of firsts. It was the year, I met some of my best friends. It was the year I completed my first 12K. The year I learned to perform a physical exam and take a full patient history. It was the year I organized my first full dinner party. It was first time I took a sexual history in the company of 5 of my peers. It was the year I moved to SF and explored the new city that has become my second home. It was the year I made my first incision, drew my first vial of blood and injected my first immunization. It was the year I started my first blog and published some of my essays. It was year I took my camera in the OR to photograph a surgery. It was the year I went to prom (it was medical school prom). It was the year I learned to suture and tie surgical knots. It was the year I was given my short white coat and the year I recited an oath that will dictate my actions for years to come and the year I became 25% of a doctor.

It was the year I realized my life was going to change, as I move closer and closer to my goal of becoming a physician and as I began to learn the fine art of balance.

Overall, 22 was year of new beginnings.
As I start 23, I hope these beginnings in my professional and personal life burgeon and take on a life of their own. Although I dread returning to the regimented schedule of lecture and school (oh how I dread the 8 AM lectures), I know I need to simply pick up my feet and move forward, drawing on my experiences. I am looking forward to moving ahead through the second year medical school in anticipation for the start of clerkships that will get me closer to working directly with patients.

I guess there are a few other things I am hoping to accomplish during 23. In no particular order:

1. Complete the SF 1/2 Marathon
2. Make it to all the weddings I'm invited to (2008 seems to be year of weddings)
3. Do more than one pull-up
4. Fully integrate swimming into my workout regimen (I just rediscovered swimming this week and love it)
5. Continue reporting to this blog with insightful (and some not so insightful) entries
6. Survive Boards Hell (and maintain a semblance of a personal life that involves time with friends and working out)
7. Figure out "which kind of doctor I want to be"
8. Get better at balancing my life, which may involved learning to say "no"
9. Continue to writing essays, including non-medical essays
10. Continue to spend time with friends and family, cultivating the new relationships that have become so central to my life and my sanity
11. Take my camera to new places
12. TRAVEL!!! (somewhere exotic)
13. Regain the swimmers tan I lost to the SF fog
14. Mentor the first year medical students
15. Continue mastering the fine art of Indian cooking
16. Speak solely Punjabi with my parents to better my ability to speak the language of my childhood
17. Continue to maintain a regular workout regimen during MS3 rotations
18. Continue to explore SF (all the museums and neighborhoods)
19. Surf and one day swim in the Pacific Ocean (if it ever warms up)
20. Meet Prince Charming
21. Stay up to date with current events and become an informed voter (go Obama)
22. Improve my Spanish
23. Smile everyday and realize how lucky I am

With the day so young (and me one year older), I am looking forward to the proximal celebrations, including a trip to the Moma to visit the Frida Kahlo exhibit with friends followed by dinner and cake with my brothers. And tomorrow will be another dinner event (Thai food) with some of my newest and closest friends and whatever other festivities we can fit into the evening.

I suppose I have created an ambitious list. Above all, I hope 23 is another year of discovery and learning and less of the enigma it has been cut out to be.

Time will tell. For now, it is time to cease the day and live it to the fullest.

Happy Birthday!

Six Rules for Doctors (and Aspiring Doctors in Short White Coats)

With two weeks remaining in my last summer vacation, I am beginning to dread the return of school. It's that same feeling I used to get right before dragging my feet to go back to school shopping. As my mom helped me fill the cart with pencils, notebooks, crayons and school supplies, I would realize I'd be leaving the carefree days of summer cartoons and frolicking for a regimented day in grammar school, full of worksheets and scheduled play time and discipline.

As I count my last days in lab (5 days), I realize I will be giving up my evenings to studying and all the other medical school commitments. Sigh. All good things to come to an end. We return August 26th.

I do still have some time remaining to muster some research results in the next five days (highly unlikely, but miracles do exist). I have reserved the last few days of summer for recharging (or spending my time with family and friends outside of SF and tying all those odds and ends).

While I was catching up on the current events on the NY Times, I came by this interesting piece outlining "Six Rules Doctors Need to Know," written by Dr. Robert Lamberts, a physician and blogger. He chronicles his thoughts about medicine and a variety of other interesting (and somewhat unrelated topics, such as "dogs driving cars") on his blog Musings of a Distractible Mind

Here are Dr. Rob's Six Rules ("they" refers to the patient):
Rule 1: They don’t want to be at your office.
Rule 2: They have a reason to be at your office.
Rule 3: They feel what they feel.
Rule 4: They don’t want to look stupid.
Rule 5: They pay for a plan.
Rule 6: The visit is about them.

Some basic Rules that are often not followed...

Just some points to ponder.

For more information: http://well.blogs.nytimes.com/2008/08/07/six-rules-doctors-need-to-know/

SF Marathon- 8.3.08

The San Francisco Marathon is the only race that allows runners to run on the Golden Gate Bridge roadway. With over 15,000 participants in the full marathon, half marathon and 5K, the city streets were flooded with runners, making their way around the course. It was cloudy and cold, but not windy nor hot (the perfect running weather and not so pleasant spectator weather)

For the full marathoners, the course starts at the Embarcadero and continues through the piers, passing the Ferry Building, Transamerica Building, Coit Tower and Fisherman's Wharf. From here, runners pass Fort Mason and the Marina. Along the way, runners are rewarded with some breathtaking views of the city and bay. Runners continue through the Presidio, onward to the Golden Gate Bridge. They cross the bridge into Marin, at which point they turn around back onto the bridge and renter the Presidio, running alongside the Pacific Ocean. They continue running into the Golden Gate Park, passing by Stow Lake, Rose Garden and Conservatory of Flowers.

From the park, runners enter into Haight and continue towards the Mission until they enter Mission Bay, passing along the Baseball park. They begin the homestretch of the race that takes runners back to the Embarcadero to the finish line and cheering fans.



I had been toying with the idea of entering the half marathon, but when the fog rolled in during the summer months, I realized training for the 13 mile race would be compromised.

I was on hand today to provide medical support to the runners as a First Aid volunteer, as part of a group of health professionals from the UCSF.

We were situated at Camp Bravo, the second post-finish tent right next to the live music and awards ceremony stage. As we helped runners by providing basic first aid, we got to hear the "Sweet Home Alabama" and various other 1980's hits that I could not recognize.

In our red hats and shirts, we made our way through the post-finish line.



I was also there to support my older brother, who was running the Full 26.2 mile marathon. It's unimaginable how anyone can run that distance. He finished in under 4 hours and I am so amazed (and proud). He has been training diligently for this race, running (sunshine or no shine)- a rule I can not abide by.

It's inspiring to see him and other runners, making it the finish and then limping to loved ones.



Maybe, with some bending of my current training policy (a requirement of sun), I may train for the 1/2 Marathon next year and be one of those limping runners at the end, who are just joyed to be done.

10 mg of Exercise minus the Exercise

Can you imagine one day being prescribed a pill that accomplishes the equivalent of thirty minutes of running or cardiovascular exercise. All this, without the sweat and pain? Seems too good to be true. But researchers may be one step closer to developing a pill that could be the answer to America's Obesity epidemic.

Scientists at the Salk Institute recently published a paper in Cell, reporting they had discovered 2 pills, Aicar and GW1516, that may be potential drug candidates. These drugs work by increasing endurance of mice that have been genetically engineered to be coach potatoes.

By examining mouse performance on treadmill, researchers have been able to demonstrate these drugs drastically increased mouse endurance. The findings were discussed in a recent New York Time’s Article titled Drugs Offer Promise of Fitness.

“One drug, known as Aicar, increased the mice’s endurance on a treadmill by 44 percent after just four weeks of treatment. A second drug, GW1516, supercharged the mice to a 75 percent increase in endurance, but had to be combined with exercise to have any effect.”

The drugs activate production of Type 1 muscle fibers, which contain a higher concentration of mitochondria, which produce energy during exercise. There are also

Type 2 muscle fiber, which do not contain as many mitochondria. Highly trained athletes have a higher number of Type 1 fibers, which allows them to perform at optimal levels—running marathons, swimming laps, cycling up steep hills, etc. For individuals with decrease fitness level, ie: coach potatoes, a great number of Type 2fibers are expected and a lower number of Type 1 fibers are present, which explains why such individuals tire easily when perform physical exercise.

The main investigator, Dr. Ronald M. Evans, has linked the increased Type 1 muscle production to a specific pathway—the PPAR-delta pathway, which has been linked to activates fat-burning processes in the body.

Dr. Evans may have discovered a potential therapeutic target. Pharmacy companies may soon be eying his discovery as a panacea to the solve a plethora of problems. If a drug was developed, it may be useful to help in treating obese or diabetic patients, who would not be otherwise able to reap the benefits of exercise.

Dr. Evans believes that “This is not just a free lunch, it’s pushing your genome toward a more enhanced genetic tone that impacts metabolism and muscle function. So instead of inheriting a great set-point you are using a drug to move your own genetics to a more activated metabolic state.”

It’s interesting how scientist are beginning to understand the complexities that lie in our bodies. Dr. Evan’s discovery gets to the molecular basis of muscle production and exercise. His research may have found a way to trick our mice into thinking they are actually exercising. I wonder if that same trick could work in humans. It will be interesting to see where this research goes.

For more information:
http://www.nytimes.com/2008/08/01/science/01muscle.html?_r=1&hp&oref=slogin#

My Essay is Live!

When I opened my inbox, I was excited to get the following message:

"Good morning, Eisha!

Your essay has been added to our homepage http://medschool.ucsf.edu/

Thanks again for letting us publish this."

I am so excited to share my essay, "Exposed" with the UCSF community. As an aspiring writer, I hope my writing can reach an audience that extends beyond just myself. In sharing my experience with anatomy, I hope others can learn about a unique experience that really changes an individual.

If you are interested, please take a look at my essay.
It is always interesting to see how one's writing is described. On the UCSF School of Medicine website, I found the following description:

"Anatomy Exposed, a Probing Essay by a UCSF medical student explores what lies beneath the skin." Now, that's a great description!

Foggy Days

I finally got to see the sun. Ok, let me qualify that statement- I got to see the sun and experience summer heat. A visit to my parents home this last weekend reminded me about a normal summer experience.

While visiting my parents, I realized a few things.

You know it's summer when you have to close the windows at noon to prevent heat from coming in and when you have to turn the fan to full power, just to tolerate breathing the warm air that circulates and fills the room.

You definitely knows it summer, when you step out for a run and start sweating the moment you start warming up and when you realize you are panting because you are thirsty (and only a mile has passed).

Oh, summer days. How I miss thee. I guess the novelty of summer is more what I miss. When I woke up on Monday morning back in SF, I was not surprised that the streets were black from condensation.

Overall, the summer has been treating me well. I've been searching for topics to write about, but realize that there is not too many interesting developments in my life. I spent the weekend with family, enjoying home-cooked meals and BBQ (we found an inventive use of the grill to heat up chocolate chip cookies) and reading novels.

I did just finish reading 1000 Splendid Suns, written by Khaled Hosseini, the author of Kite Runner. It was an interesting story about the plight of Afghani women set on the backdrop of the tumultuous history of the a country that continues to emerge in the forefront of media coverage.

***
If there is one word I can use to describe the epitome of my summer vacation, it would have to be ROUTINE. I spend my day in the lab, working out research problems that sometimes transcend my understanding while completing parts of my curricular project. That leaves late afternoon for a gym trip or running. I've been working on fitting in swimming (the weather just has not been that cooperative for a girl that is used to swimming under the blanket of the sun's glow). And evenings are left for Food Network, reruns of Sex and the City or surfing the web.

I'm working on writing a piece about DNA use in criminal investigations. I am also looking forward to photographing volunteers and patients at Clinica Martin Baro this Saturday.

With the sun shining and the weather looking promising right now (Wednesday), I think it maybe time for a run out to the ocean, if I can get out of lab at a decent hour and beat the impending arrival of SF summer fog.

Cheers to summer days!

Take 1, 2, 3, 4.....

With the overhead lights arranged in a circle around the dissecting table, I looked into the view finder to see the scene. The blue towels covered the thorax and lower abdomen. The plastic body bag glistened as we toyed with the light.

Once the lights were arranged perfectly (or close to perfect) and the glare was reduced, we began filming the renal anatomy dissection in the anatomy lab.

As part of my curricular project, I am helping to produce a renal anatomy lab video for a renal anatomy lab that will be added to the first year curriculum next year. I am working with the an anatomist and surgeon to create this film and to write the syllabus that outlines the "Anatomical and Surgical Approach to the Kidney."

The surgical procedure that will be outlined in the syllabus is used to remove a kidney for radical nephrectomy in treatment of cancer as well as organ recovery for transplantation. With the incision made, my surgeon mentor, dissected away until we reached the right kidney. As he moved deeper in the abdomen, fluid flooded out (which required repeated blotting and a few movie takes).

He navigated through the peritoneum until he found the right kidney. With the right kidney in his hand, he carefully began the process of removing the kidney from the abdomen by severing and tying off the renal artery, vein and ureter. He pulled the kidney out of the cadever and bissected the kidney to show the interior anatomy with the pyramids and columns.

After filming this anatomy lab video, I have developed a new appreciation for movie producers. It takes a number of takes to get the cut just right and so much thought goes into creating each scene. And this is just the pre-production phase.

The next stage will involve revising and splicing the scenes to creat a fluid film that will instruct students how to remove the kidney. In the process, I too will learn this process (inside and out). Let the revision began...

End Scene

The Summer...

I am used to sunshine, heat, long days and humidity during the summer time. As long as I can remember, I have associated being "hot" with the lazy days of summer. For some reason, it has not really hit me that is summer.

Perhaps, it is the rolling fog or the bone-chilling weather in San Francisco that makes it a little confusing. It feels like winter even though it is July 1st.

Well, I really can not complain- I'd take the fog over 100 degree heat any day!

I do not have much to report. I have started my basic science research. DNA extraction and PCR revisited. And I have also started my curriculum project, which involves integrating a surgical approach in the Organs Block. This week has been orientation, learning the ins and outs of developing learning objectives, storyboarding and laying out the direction of the project.

Overall, I am trying my best to stay on top of the list of things to do, while enjoying the summer nights with gym trips and time spent with my friends...my psuedovacation.

25% of an MD

Yesterday, I was staring at the ocean, thinking about how beautiful the water looked and how I longed to be anywhere but the library. I was thinking about the old saying- "there is always light at the end of the tunnel." This may be true, but the creator of this saying did not realize that some tunnels are longer than others. And the tunnel that takes one through studying for the BMB final, is a really long one. At least now, I can see the light.

It's hard to believe that I am one quarter of a doctor. Ok, I say this preemptively contingent on passing our BMB cumulative final.

I will savor the moment and the feeling of being DONE! We are officially second year medical students, popularly know as MS2s, which means the expectation bar has just gotten so much higher. We can no longer use the excuse that "we are just first years..."

When I turned in my final to the BMB course directors, I realized that this is it. They looked at me, and said "Congratulations." It took me a second to register that they were referring to be being done with the first year of medical student.

There is something fulfilling of transitioning from being a first year medical student to a second year medical student. Although, I have yet to figure out what it really is. In this moment, I am just looking forward to 8 weeks of class-free days. Time to recollect myself and tend to the long list of things to do in San Francisco.

Just about a year ago, I was donning a black gown and square hat, during my college graduation, leaping away from college and inching towards medical school. I remember how excited I was to start medical school. There was the joy of venturing to a new city and a new life, a life that would allow me meet so many unique individuals and to live my lifelong dream of serving patients.

I had no idea what to expect. I was bright-eyed and ready to do most anything (ok not really). I was most looking forward to learning my patients stories and helping them as they coped with their medical conditions; I was excited about learning and becoming versed in all the common acronyms endemic to medical jargon. I was hopeful that I could touch my patients lives.

As I sit here reflecting and thinking back to a time not so long ago, I realize that the first year of medical has been unforgettable, surpassing my initial expectations. I have been humbled by being allowed to enter my patients lives in a whole new way, whether it be taking a medical history, performing a physical exam or assisting in a operation. I have been immersed in a unique learning experience that has taken me to new depths; I have surprised myself and seen myself grow, as I confront the social and cultural complexities of medicine.

I have been privileged to navigate the geography of the human body in anatomy lab, dissecting away skin, fascia and muscles to better view the organs of the body of our donor, who we know nothing about. I have learned so much and forgotten most of what was presented in lecture, but I do remember the patients I have worked with away and walk away with a deeper appreciation for the complexity of the human body, in all its strength and fragility. With a better understanding of the human body, I am poised to embark on the next stage of my medical school journey- working with patients and making medical diagnosis.



In less than a year (April 28, 2009), we will transition to the clerkships. I still struggle to translate my patent's chief complaint, history of present illness and symptoms into a diagnosis. The second year will hopefully allow me to better master this nebulous art. Time will tell...

With the first year pocketed away (pending no e-mail from the course directors), I will now attend to some MS 1 wrap-up activities. Here are the things I need to do:

1. Wash my white coat (it's getting a little dusty and the pockets are bulging, so I might need to purge some of the useless papers that have made residence in the pockets)
2. Bury the MS 1 syllabus somewhere in my closet (I won't be looking at these for some time)
3. Change my e-mail signature from Eisha Z, MS 1 to Eisha Z, MS 2
4. Clean my room (and apartment)
5. Write out my summer to do list.
6. Proceed to completing things on my San Francisco "to do" list (it's a long, ambitious list that mostly is concerned with visiting different neighborhoods, hiking, visiting museums, eating at specific restaurants, spending time with my friends, running, swimming, learning to surf, and the list goes on and on...)

I am looking to forward to the summer vacation. Albeit, it's not a vacation in the traditional sense; I will be sticking around San Francisco and completing a research project and curriculum.

In looking back to my first year, I have really enjoyed writing in this blog; I have no idea who reads this and what others think about me and my path in medicine. I certainly hope I have been able to share my thoughts and reflections to give others a closer view of medicine, as I begin to see medicine. Most importantly, I hope you have enjoyed reading and gained something. I look forward to continue writing (I need to update my profile to reflect that I am a second year medical student). If you stay tuned, you will invariably see some of my latest photographs, hear about my work and life.

For now, I am going to cease the day, knowing that I am 25% of the way to becoming a doctoring! Wow!