Happy Birthday Baby A & Baby B

Baby A and Baby B were delivered today. Happy Birthday Baby A and Baby B!

I am happy to report that both babies and mom are doing well.

I was not paged (they must have forgotten); so I was unable to be at Jane's side during the delivery. She had assigned me to take pictures of the birth.

I am little disaappointed that noone paged me since I was looking forward to be there with her during this important part of her life. But pregnancy never really goes according to plan or schedule. So, sometimes there is no way to know.

I am exciting about finally meeting the two babies and actually getting to see them in person, instead of through a black ultrasound screen.

Can't wait to finally meet the two and learn their real names!
***

The first pager

I got my first pager today. The small black square noise box was sitting in my box this morning. There are two buttons on the pager- a red and green button. I am still fiddling with the two commands as I wait for the pager to go off-- a signal to report to Labor and Delivery.

My U-teach mom, Jane, will be delivering this week through a C-section. The procedure has been scheduled, but there is no way to plan such events, hence the pager comes in use. It's hard to believe this day is approaching. We're in week 35 and by delivery date it will will be week 35 and six days (so, essentially week 36).

I finally gave Jane her gifts today: denim overalls with a pink shirt for the Baby girl and a blue-stripped baseball inspired outfit for the Baby boy. For Jane I got her a delicate heart necklace.

When I dropped by her room after preceptorship, I was just telling her how I strongly think the mother deserves gifts because they go through so much: carrying the baby, experiencing a transformation as their stomach and body expands, undergoing pain, sacrificing sleep and so much more.

Being at her side has been an amazing learning experience and the next few days will be remarkable as we welcome Baby A and Baby B into the world (finally). Stay tuned...

Rx in the City

You may be able to think back to high school and the night of your prom, the festivities, the preparations, and the awkwardness that permeates adolescents in any setting. I actually did not go to my high school prom, so I am completely basing my perception of prom on accounts from my closest friends.

I think when I vowed to stay home on prom night, I never thought I would get a second chance to live the experience. And it was quite an experience.

For the gentlemen the dress attire means suits, tuxedos (or tuxedo shirts) and for ladies that means shiny dresses (that are usually low-cut and very uncomfortable), sparkling jewelry, and those oh-so-dreaded stiletto heals that make you feel like a movie star but make your feet ache after 10 minutes of walking (basically the time it takes to arrive on the party scene). The combination of glimmering ladies and suits makes for an unforgettable evening with its share of awkward moments (not too removed from the days of highschool since we are such a small class).


This year's Prom was "Rx in the City" (a nerdy spin on Sex in the City, one of my favorite television shows) and it was held in the Carnelian Room, which is perched on the 52nd Floor of a downtown high-rise. What was most amazing was the breathtaking panoramic view of the entire city at night. The skyline was visible amidst the rain droplets that trickled down the windows.

The prom itself was good times with classmates. The drinks were pouring (each ticket allows for one free drink and additional drinks cost $$$), the music was loud and hit or miss with a mix of techno, salsa, pop, and other songs. The space was limited, but there were corners near the windows where you could seek refuge. And the dance floor was quite a scene, as classmates pulled out the moves (which I thought they never had) and lip synced to songs. It was almost impossible to recognize some individuals out there.

All in all, I had really great time dressing up in my long red dress, having dinner with a smaller group at the pre-prom party at Delancey Street Restaurant in the Embarcadero and being addressed as "maam", having valet service, taking photographs, smiling all night as flashes went off, and spending time with my classmates and closest friends.

At least now, I have these memories of a beautiful evening and I actually say that I went to prom (and we can leave it at that).

***

Happy Aniversary CMB!

I had never seen green cake until today. The tres leche (three milk) cake that we ate during clinica this morning was sweet and moist. And what was even greater than the beautiful pink flowers adorning the top of the cake was the purpose behind this cake, which was to celebrate the one-year anniversary of Clinica Martin Baro, a student-run clinic that offers free health care to underserved patient populations in San Francisco.

Undergraduates from San Francisco State University run the clinic, making it possible for UCSF medical students to serve and learn from the patients. Most the patients visiting Clinica are Spanish-speaking, which makes for interesting patient interviews given my limited Spanish proficiency.

Today was not too busy. So, my classmate and I had an adequate amount of time to interview our patient and perform a directed physical exam. She masterfully lead the interview with impeccable Spanish, while I listened intently, occasionally picking up lines and words that were vaguely familiar from another lifetime (high school Spanish).

There is something about listening to your patient. I mean listening outside the medical box. We are programmed to identify pathology, cluster symptoms, make diagnosis and scrutinize over details. But sometimes we forget to really listen to the person sitting in front of us given our time limitation.

Mr. S was a painter by profession and his favorite color is "azul" (blue). During one part of the interview when I asked him about his "hija" (daughter), he asked me a favor: he wanted to stand up. For some reason, I was as tall as his daughter and resembled her. Interesting...

Our interview was not limited by the "15-minute" window that is prescribed in the real medical world. We had ample time to really get to know Mr. S outside his medical history. We actually learned his history.

We finished clinica early, which was an unexpected gift since I had planned for a long day in clinic.

The extra time was exactly what I needed to catch up on sleep and prepare for tonight's big event- The Medical School Prom (more details and pictures to come). I have been contracted as the unofficial photographer (well I've actually just kind of volunteered). We'll see how those pictures turn out...(Stay tuned)

***

Image: http://www.ucsf.edu/clinica/images/clinica_logo.jpg

Renal begins...

There is nothing much like using a condom to demonstrate how changes in pressure and resistance alter filtration rate in the kidney. And so, renal begins...

The kidney may look simple with it's bean-shape, but it is quite the organ. According to seasoned second years, who are known for spreading rumors, renal is supposed to be hardest organ block. And this rumor was corroborated by our course director.

I wonder how much truth there is to such a rumor? I mean the kidneys are just fancy filters that take our blood, filter the things we need (and put them back in our blood), until there is nothing left but urine. How hard can it really be?

Well, my simplified model does no justice to an organ that is vital for eliminating urine, maintaining blood volume and pressure. The mystery surrounding this nebulous organ will unravel as we progress through this block.

And I guess the best way to celebrate the end of Pulmonary is with a Medical School Prom tommorrow night. I will report back about this momentous occasion. Hopefully, the rain will calm down, so I won't have wet feet.

Image:
http://galileo.phys.virginia.edu/classes/304/kidney.gif

Pulmonary: Take-home Points

Today was our last day of Pulmonary block. We ended with a presentation from a master clinician.

"It's nice to be called a master clinician at least once a day," said our presenter.

Today's presentation was from a pulmonologist, who has extensive expertise in Tuberculosis. Interestingly, one-third of the world's population is infected with TB (1.7 billion people). As expected, TB also represents the leading cause of death due to an infectious disease.

As the studies continue for tommorrow's Pulmonary Exam, I figured I would summarize with the take-home points. See, medical students sometimes have a tendency to scrutinize over the details, akin to paying close attention to the leaves and needles rather than looking at the forest. I am definitely a forest-lover and seeing the big picture remains most important.

In summary, here is pulmonary in a few take-home points:
1. The lungs are two flappy sacs that get bigger and smaller to let air in (inspiration) and air out (expiration). Just do not tell this too a pulmonologist; it may be offensive.
2. Air contains 02, which travels into the blood and tissues. C02 needs to leave the body, otherwise bad things happen (your blood gets acidic and we don't want that to happen, do we?) 3. SMOKING IS BAD--> Smoking introduces toxins that destroy the intricate architecture of your lungs (causing collapse and destruction), making it harder to exhale. So, if you smoke- please quit (you can prevent this!)
4. Asthma is caused by an immune system that goes crazy and sensitive. If you have asthma, try to avoid the things that set off your immune system, even if that means putting up Garfield up for adoption. My apologies.
5. The mechanics of breathing are complicated. Just think pressure (moving from high pressure to low pressure).
6. There are just too many restrictive lung diseases...
7. The chief complaint for most any pulmonary (and usually cardiac) disease is shortness of breath. So, if you present with shortness of breath, the differential is long and so is the work-up.

Ok, I'm procrastinating. Time to return to pulmonary world. Here is the most important take-home: Next time, you plan to use the line: "You take my breath away," to woo anyone, please be sure not to drop this pick-up on a medical student. We will just be concerned that you may have a pulmonary dysfunction.
***
Here are some photographs that I took at the UCSF Library. Images illustrate the powerful influence of advertising on promoting smoking. What strikes me most is the young boy (below), with a cigarette. We've come a long way, thankfully...

Getting the Blue Card

The only blue card left on the table was labeled “R3.”

Today would be the day I would be the third-year resident, coordinating and leading a team of nine health care providers, during our patient simulator session at the San Francisco General Hospital Simulation Center.

I knew I was running late today. Four hours of lecture and small group this morning was enough to give me an appetite. So, a quick trip to Subway was in order for a foot-long veggie sandwich (I never seem to get any satiety from the six inch subs). But the line was not quick and the bus ride on the blue shuttle took longer than expected, making me arrive at the General just in time to get the last unwanted assignment.


All my other classmates had arrived earlier and snagged the RN, fourth year medical student, third year medical student, Respiratory Therapist and intern positions. I was left with third year resident position.

I have no idea why anybody would not want be an R3. You simply watch over everyone and assign tasks. The only caveat is that everyone turns to you for guidance and answers. And you have to report back to the higher powers.

Our patient was Mr. Webster. He was complaining of dyspnea (shortness of breath) and chest pain on inspiration. The differential diagnosis for his chief complaint is akin to opening Pandora’s Box of pulmonary and cardiac diseases. I'll be spending my weekend studying this material for our upcoming Pulmonary Exam.

On appearance, you’d know right away that something was clearly wrong; Mr. Webster was not just breathing hard, he was made of plastic and had a mechanical motor for a heart. But as our real fourth year medical student leader put it, “he is more than a dummy.”

In fact, he is a patient simulator that allows teams of health care providers, everyone from first year medical students to physicians to nurses, practice and work together during simulated patient cases. Mr. Webster can become tachycardic, hypotensive, ischemic, and hypoxic—with the push of a few buttons. And he can talk, moan and tell us his story. We just have to ask all the right questions.

As health care providers we work so hard to prevent any types of events that endanger the lives of our patients. The last think you want to hear is CODE BLUE, while your patient slips away. But when we do find our patient in distress, we need to know how to act and simulating such cases makes us better equipped to serve our real patients.

And being an R3 really is not that bad.

Shades of Gray

As I sit here in lecture trying to make sense of high resolution CT X-ray scans amidst a somnolent backdrop with lights dimmed, I feel a sudden urge to sleep. At the same time, I can't help but think that all these images look virtually the same (ok, not really, but close enough that it's incredibly difficult to distinguish the difference between honeycomb lungs and ground glass lungs that we see in different lung diseases).

And then there is the challenge associated with identifying infiltrate in lung X-rays based on opacity (looking for white or gray areas), which the radiologist admits "takes years of experience."

In a normal lung X-ray, the lungs appear as two big black sacs with heart snugly sitting in the middle. The lungs should be filled with air (air turns out to be black, since it does not absorb the X-rays). If there are abnormalities, such as fluid build-up in pneumonia, gray or white areas will appear where fluid is located, since fluid can absorb more X-rays.

The trick is playing close attention to details and identifying the abnormal by making sense of the shades of gray.

***

Image 1: http://www.cmj.org/paper_journal/03/11/01/yx19h12.jpg

Image 2: http://www.texascollaborative.org/Puccini%20Module/images/chestxray.jpg

Beyond Awareness-Effecting Change

Are you in a relationship that makes you feel scared? Have you ever been threatened? What happens when you and your partner fight? Has your partner ever shoved, pushed, hit, kicked, choked or hurt you? Does your partner ever force you to have sex?

In screening for intimate partner violence, one must remain non-judgemental while asking such questions. It is not in our position to question, why a victim of physical or emotional violence, remains committed to their partner. We are there to serve the best interests of our patients.
*
"Beyond Awareness-Effecting Change" was the theme of this year's 8th Annual Domestic Violence Conference on Saturday in Cole Hall on the UCSF Parnassus campus. This theme was threaded throughout the day-long conference that featured two key-note speakers, a health care provider panel, break-out sessions that addressed how to confront issues relating to domestic violence, and a survivor panel.

Although I attended this conference, I am struggling to define "domestic violence." I think if images of bruised women, helpless children, violent acts against those who can (and will not) fight back, angry perpetrators seeking power, alcohol-induced behavior, psyschological trauma...images that blurr and coalesce to create an image we can not bear to look at or even think about. I wonder about the darker side of human nature that would steep such a low level to cause harm.

But domestic violence, a term loosley used to describe family violence and intimate partner violence, happens and is a reality many women, children and (some) men face. So, we must be prepared to open our eyes to these images.

How do we confront issues of domestic violence as health care providers? The message was clear, we must maintain a high index of suspicion in certain cases, screen appropriately (and do so in a way that does not endanger the family or exacerbate the situation), and rely on an interdisciplinary approach by employing all members of our health care team.

As simple as it is to want to rescue a woman in distress, we must recognize that some woman are still in love with the perpetrator. Especially in countries, like India, a high value is placed on preserving marriage at any cost, even if it comes at the expense of physical or emotional abuse.

Some women may hold on to a twinge of hope that things will change. For this reason, we must meet victims where they are and realize change is gradual and will not happen overnight. But at the same time, we must educate victims about what a healthy relationship looks like, rebuild their shattered confidence, and provide the necessary resources (hot lines, social workers, shelter information, police contacts, etc).

I walk away from the conference with a deeper understanding of how to effectively serve patients, who are victim es of intimiate partner violence. I am still in the infancy stages of learning how to screen for domestic violence and how to procede if a patient confides in me. But I have heightened awareness about an issue that I will sadly confront in the years to come.

***

Images: I was the event photographer for the conference. First image: Healthcare Provider Panel.

Babies in a Playground

"They are talking to each other," said Jane during her doctor visit today. We were finally reunited after a long Christmas break. Since our last meeting in December, Jane has grown considerably larger. Her stomach is larger and more round and I noticed swelling in her hands. She was accompanied by her mother.

As she gets closer to her due date in March, she will have more routine visits to check the babies, monitor their heart rate and development, and asses her overall health and progress to delivery. In the third trimester, a mother's biophysical profile (BPP) is measured by examining the baby's heart rate, muscle tone, movement, breathing, and amniotic fluid levels.

With twin pregnancies, women have a higher risk of developing preeclampsia, a condition that impedes blood flow to the placenta. Elevated blood pressures, swelling, and protein in the urine are all signed of preelampsia. So, Jane will be closely monitored until she delivers.

Today, Jane was seen in the antenatal unit. Ultrasound was used again to visualize the babies, determine their position (how their heads were oriented), and to measure the black fluid patches that make up the amniotic fluid.

Jane was so excited when she could make out the little white joint that was the Baby's A knee.

Once the fetal heart monitor was fastened on her stomach, we could hear each babies racing heart, sometimes interrupted by a swooshing sound.

The babies have made their way up and their two heads could be seen right next to each other. Their faces are more defined and I could make out Baby A's, little ear and nose. It looked Baby A and Baby B were communicating with each other, whispering secrets into each other's ear.

Jane placed my hand on her stomach and I could feel their heads.

"They are playing in my stomach," she said.

It's hard to imagine what kind of playground the twins share and what it feels like for Jane when the babies move around in such a small space. They are growing and moving more frequently, swimming, and moving their hands and feet, as if to tell us "look at me."

All eyes were definitely on the babies as they played in a world all their own.

Image: "External Fetal Monitoring." http://www.fetalmonitorstrips.com/07024_02X.jpg

Research Day!

Today was an exciting day. It was "research day," a day filled with poster and oral presentations about research conducted by UCSF Medical students. And for those, who are nerds at heart (myself included), it was equivalent to research "show and tell."

Milberry Gym was transformed into the UCSF Summer Research Symposium headquarters, complete with a easel for poster displaying, a stage, and smorgasbord of food. It took me back to the days of undergraduate research, national conferences, and presentations of research findings. Feels like another lifetime.

The posters were shiny and colorful, displaying a diversity of topics, everything from the basic science of neurological conditions to the analysis of global poverty.

My poster could be found among the sea of posters right under the basketball hoop. I had the pleasure of studying cervical cancer and HPV infection over the summer and produced a pretty poster to summarize 8 weeks of work into chunks of information and images.

If you ever find yourself at a research symposium and want to know the essence of any research poster and are intimidated by either the presenter guarding the poster, or just do not feel like being bogged down by endless details that you will invariably forget the moment you walk two steps to the right to view the next poster, I give you this one piece of advice: read the title (it says it all).

For example, my poster was titled: "Identifying Immunosuppressive Mechanisms in the Mucosa of HPV-infected histologically normal Cervix." I know its a moutful, but long, incomprehensible titles are the latest fad in science. And my research can basically summed in this one line.

What I found most amusing is when I was asked to give the "1 minute summary" of the research. Wow! It definitely takes some creativity to tell the story of HPV and cervical cancer and my project in such a short amount of time. And repeating the same story numerous time never lost its novelty.

I really enjoyed learning about my classmate's research interests, which is quite impressive, especially the Dean's Prize Winners, who have really made strides in their fields. Special congratulations, to Stephanie C, a fellow UCSF Med Student blogger. Also, sharing my research with the UCSF Community was an honor and pleasure.

I look forward to the next Research Day!

School Starts along with the Rain

"It's only 122 steps." The stranger was referring to the number of steps making up the 9 flights of stairs that take you from level I to level A. Earlier today we were experiencing some temporary power outages, so the elevator was out of the question. But I still had to deal with the torrential rains, gusty winds, and bone-chilling weather.

Is it ironic if you love to exercise but hate to climb the stairs? I face this dilemma everyday. Well, at least I can tolerate going downstairs when gravity is on my side.

Learning about Arterial Blood Gases was so much more interesting in the hallway on the bottom of the stairwell instead of in the darkness of our classroom.

Returning to San Francisco on Tuesday night brought me back to a city I love and rudely introduced me to the gloomy, cold, rainy weather I dread. Now it really starts to feel like winter.

So far our first half week has been uneventful. We said farewell to Cardio in December and we have begun Respiratory, our next Organ Block. Three days into Respiratory, I am already playing catch-up.

Although I miss the structure-less days of vacation, I am starting to settle back into a schedule and a routine. It's hard but being confined indoors makes it a little easier (or it should). We'll see..