Friday, December 24, 2010

How not to pee while at the movie theatre...

Being in medical school, I have friends and acquaintences asking me for medical advice all the time. This was particularly disconcerting when I was a first year student and knew little to nothing about medicine. As a third year student, I feel much more comfortable answering these questions because I have learned so much over the previous two years and I have a much better idea of what I don't know, which means I have a better idea about when I should recommend that the friend sees their physician. Most of the questions I get asked start with "I have this rash..." or "I've been feeling under the weather..." but every once in a while I get a more interesting question.

A friend of mine was watching a movie and had to urinate causing him to miss an important scene. Never wanting to go through this again, he wanted help in developing a strategy to avoid a similarly horrendous experience in the future. His one caveat was that he didn't want to give up his 2L pop while at the theatre (yes, drinking 2L of pop at a go is unhealthy, he doesn't care, move on...). One idea was self cathetrization, but he didn't really like the idea of inserting a tube into his urethra (there is also a significantly increased risk of urinary tract infections, so don't do this...).

Alternatively, he could just make sure he ate salted popcorn while at the theatre. How does salted popcorn help? Well, he had to urinate during the movie because he was consuming 2L of fluid and his kidneys were flushing this extra fluid from his body. However, if he ate salted popcorn, this would increase the concentration of sodium in his blood. To bring the concentration of sodium back down to normal levels, his kidneys would initially have to retain fluid...thereby reducing the amount of urine they produce. Over the next few days his kidneys would excrete the excess sodium and the fluid that was retained with it to bring his body back to normal fluid volume and sodium concentration. However, in the short term, producing less urine while watching the movie means that he would not have to pee until the movie is over.

Of course, there are a lot of reasons why consuming excess salt is a bad idea, but this friend is a healthy guy, so his body can take a short term excess sodium load. So this idea will work well for him.

Thursday, December 23, 2010

Kid with a fever....remember Kawasaki disease!

If a kid has a fever, 99% of the time it is due to a cold/flu/infection. 90% of the time, the correct course of treatment is rest and fluids. If the infection is a particularly nasty bacterial infection, then antibiotics are in order. Honestly, antibiotics are rarely necessary and we definitely over prescribe them; however, this is not a post on the evils and consequences of over prescribing antibiotics.

This is a post about one of the multitude of causes that is responsible for the 1% of pediatric fevers that are not due to an infection. When I was doing my pediatric rotation, I saw a boy who had a fever for 7 days. His pediatrician assumed that the boy had an infection and sent him home without doing a thorough physical exam. Over 99% of the time, this would have been okay. Unfortunately, this was a rare occassion where the pediatrician really needed to perform a thorough examination on this child.

If the pediatrician had taken a more thorough look at this boy, he would have noticed a strawberry tongue, rash, swollen lymph nodes, and peeling of the skin around his hands and feet. The boy had Kawasaki disease. Kawasaki is an autoimmune vasculitis which results in the patient's immune system attacking medium sized arterial vessels. If this boy had been diagnosed when he saw his pediatrician, he would have been admitted to hospital, started on IVIG, and I would not have a story to write about. Unfortunately, he was not diagnosed until months later, when he developed a consequence of Kawasaki disease...coronary artery aneurysms. Now this boy is at increased risk of cardiac a child.

The lesson here isn't to always assume that your child has Kawasaki disease if they have a fever. The lesson is to make sure that your pediatrician, or any doctor you see for that matter, shows an effort to be thorough. If you have a doctor that is only willing to spend 2 minutes with you, it might be time to find another doctor. Now, it is unrealistic for you to assume your family doctor will spend 30 minutes with you if you have a cold...but if you really feel sick and your doctor doesn't seem to address your concerns, are you really receiving the health care that you want?

Monday, December 20, 2010

Pediatrics as a Med Student

My first third year rotation was in pediatrics at my province's major pediatric hospital. Pediatrics is a great first rotation because the attendings, residents, and nurses are used to dealing with children, so they are patient. At the start of third year, patient co-workers are probably the most essential part of our learning because we have very little practical medical experience.

Learning how to function in a hospital as a medical student isn't easy. We are learning how to manage our patients both medically and personally; understanding the medicine isn't useful if we can't build enough rapport to elicit a history. We also have to bridge the gap between the attending physician/residents and the rest of the hospital staff.

Throughout the first two years of med school, we are constantly warned about third year because being at the bottom of the medical team totem pole is a terrible place to be. Why? Because crap really does slide downhill... If the medical team is upset with the nursing team, they yell at us. If the nursing team is upset with the medical team, they yell at us too. At the same time, we are never supposed to demonstrate any outward signs of distcontent at the anyone. The mentality is: "you know how many people tried to get into medical school but didn't, you're lucky to be where you you should thank me for telling you that you're incompetent because you didn't do the thing I forgot to tell you to do".

However, my experience in pediatrics was fantastic because all of the staff were interested in teaching us and most realized that we were in the infant stages of our training.

Another challenge in pediatrics is dealing with patients. We have all worked with patients in first and second year, but now we actually have to manage acutely sick patients for the duration of their hospital stay. Particularly difficult in pediatrics because kids are not rational, dislike waiting, and often fail to communicate important issues. We are told to rely on parents to liaise with their kids...this is often a good idea, but sometimes it's actually a terrible idea. Having a child who is sick enough to come to hospital is a stressful situation and some people deal with stress better than others. Some parents are calm enough to provide excellent histories that thoroughly describe their child's problems. Other parents are too overwhelmed by their child's illness to be able to remember anything relevant about their child's health. Histories are usually more important than any physical exam or laboratory investigation we can undertake. Thus, if we don't get a good history, we are much slower at starting the correct management for our patients. Delays in management mean extended hospital if you don't want your kid to be in hospital any longer than they need to be, make sure you can provide a good history!

So my take on pediatrics as a med student:

1. The staff are usually very friendly and easy to work with.
2. Patients are usually a lot of fun to interact with.
3. Kids rarely want to stay in the hospital any longer than they absolutely need to.
4. Kids usually get better.
5. Kids are hospitalized for reasons that are not there fault (i.e. Not too many kids come into hospital with a COPD exacerbation from smoking).

1. Patients with only one issue to manage...kinda boring.
2. Often can't rationalize with a kid.
3. The bread and butter pediatric patient is either ADHD or failure to thrive.
4. Pediatrics requires very very detailed paper work.
5. Limited job opportunities if you want to sub specialize.

I had a lot of fun in pediatrics, but it is definitely not the specialty for me. In the end, I think I would get bored in the long run.

Saturday, November 13, 2010

Rural practice: it's a small community

In my medical school, as with most medical schools in North America, we spend our first two years in lectures and our last two years in clinic/on hospital wards managing patients. Our first practical rotation, rural practice, begins during the summer between 2nd and 3rd year.

In rural practice, we work one on one with a family doctor for a month in their rural community. A reality about practicing medicine in a rural community is that you cannot be a jerk...because you will quickly go out of business. The same can be said to some degree about practicing medicine anywhere, but in small towns everyone knows everyone...and they all talk.

During my rural rotation, I met an internist who was constantly complaining about the lack of business in his town. I started thinking that small towns couldn't support specialists because there just weren't enough people that required specialized care. Then I met two of the other internists in the same community, who were telling me that they needed more internists to help with their ridiculous patient load.

Why was there a discrepancy? Turns out the first internist lacked interpersonal skills. He would seem disinterested in patients when he was meeting with them and he would criticize the family doctors, who are the physicians who actually refer patients to him. This meant that the family docs didn't refer their patients to him, which was fine by the patients because they didn't want to be referred to him either.

Now this scenario could happen anywhere, but it will happen much more quickly in a small town where everyone knows everyone. In a big city word doesn't travel as fast and a rude doctor is more likely to be able to maintain his practice, but if you're in a small to be nice if you want to work...

Friday, September 10, 2010

Why you gain weight after a big meal

Why do you gain weight after a holiday meal? Well, the obvious reason is that holiday meals are loaded with calories, but since it takes roughly 3000 excess calories to create a pound of fat... The calories aren't responsible for the entire 3-4 pounds you put on the day after Christmas. Actually, water and your kidneys are primarily responsible for that.

You see, holiday meals often consist of a lot of salt. Your kidneys are responsible for regulating your body's salt concentration. Kidneys regulate salt in two ways, one, they decide to excrete more or less salt out of your body through the urine, two, they decide to excrete more or less water out of your body through the urine.

Kidneys regulate the body's water on a minute to minute basis, but they regulate the body's salt on a day to day basis. So, when you take in a ton of salt during that thanksgiving meal, your body's salt concentration immedialtely increases. Your kidneys' respond initially by retaining more fluid than they normally would (meaning you pee less). This extra water returns your body's salt concentration to normal, even though your body's absolute salt levels have increased (I.e. You are retaining water). Then over the next few days your body pees out the excess salt and retained water, keeping your salt concentration normal and bringing the absolute amount of salt in your body back down to normal levels. When you lose the water, you lose the weight.

Monday, August 9, 2010

Do not bring us your poop!

If your stool needs to be cultured for bacteria or looked at under the microscope for parasites, it needs to be sent to the lab. There are pathologists who work at the lab and they are trained to examine your poop and figure out a diagnosis. However, pathologists are the only doctors that are truly trained to do this. The rest of the medical community, by and large, has no idea how to examine your poop. So please, do not come into a clinic and show people a jar of your feces after lunch (or any time, really) because we will not be able to do much more than comment on the colour and smell. And really, we’d rather not have to do that either…

Sunday, August 8, 2010

Normocytic B12 deficiency anemia...not necessarily a nutrition problem

Sorry, this post is a little more technical than most, but I thought it was interesting enough to share...

I saw a patient today who had chronic normocytic anemia. The patient was an older man, so the most likely cause of his anemia was chronic bleeding.

The patient has had bladder surgery in the past and had high creatinine values recently, so his doctor's initial impression was that the bleeding was likely from the urinary tract, which is a very reasonable theory.

Urine tests found some microalbuminuria, but no hematuria (blood in the urine) or proteinuria. Basically, his urinary system had nothing to do with his anemia.

Initial test results showed that he was iron deficient, but his anemia was normocytic, not microcytic, so a CBC looking at B12 and folate was ordered. His folate was normal, but his B12 was low. Iron and B12 deficiencies explain why the anemia was normocytic, but why was he B12 deficient? He was not an alcoholic, nor was he malnourished...he should be getting enough B12.

My running theory is that the chronic bleeding is coming from the GI tract, specifically, the stomach. He has peptic ulcers that interfere with his production of intrinsic factor and prevent him from absorbing B12 from his diet. These ulcers are also bleeding, causing his anemia.

Thursday, August 5, 2010

Caffeine, smoking, blood pressure, and headaches

Man has massive headaches that force him to stop doing whatever he is doing, sit down, and pray for them to end. These happen transiently and often.

He goes to see his doctor.

He sees doctor's med student instead.

Med student notes he has had blood pressures of 200/100 in the past. Last visit was one week ago and he had a blood pressure of 160/100. Med student decides to check his current blood pressure, it is 160/100. High blood pressure causes headaches.

Med student asks man if he takes his blood pressure medication. Man says no. Med student suggests he starts.

Med student asks man if he smokes. Man says yes, 1 pack/day. Nicotine causes vasoconstriction which increases blood pressure. Med student suggests he stops smoking.

Med student asks man if he has caffeinated drinks. Man says yes, 1 pot of coffee/day and 6 pepsis/day. Caffeine causes vasoconstriction which increases blood pressure. Med student suggests he stops drinking coffee and pepsi.

Med student is jaded because he has heard hundreds of stories about patients being given good medical advice and ignoring it.

Man comes back next week. He quit coffee and pepsi. He cut smoking down to 1/2 pack/day. He started taking his meds. His blood pressure is 130/90. His headaches are gone. His med student is not jaded anymore.

Monday, July 26, 2010

Medical Student Line of Credit

One of the major pitfalls of going into medical school is debt. Currently, some of my friends like to imply that I should be taking them out for dinner because I am going to be so "rich" when I become a doctor. Ignoring the fact that most people have enormous misconceptions about how much money the average physician actually earns, I always have to point out that I am not a doctor; in fact, I'm a student...which is as far from being "rich" as possible.

Enrollment into medical school has a ridiculous price tag. Now, our tuition isn't as much as most MBA and dentistry programs, but we also have 2-5 years of poorly compensated residency (read: slave labour) after we finish our four years of school. Keep in mind that very few medical students hold down jobs while they are in school because, school is busy.

So how do med students afford medical school? Some have wealthy parents who are willing to help out, others worked and saved in their pre-med years, and most end up taking out a line of credit.

Now, normally, if I went into a bank and asked them for a $150-200K line of credit without having any income or collateral...mass hysteria would ensue. However, many banks have professional student lines of credit. These are lines of credit that are intended for student doctors, lawyers, dentists, etc. Of course, these banks aren't extending a line of credit, at prime I should add, to professional students as an act of kindness...I'm not sure banks are truly capable of acts of kindness. The strategy behind these lines of credit are that professional students will soon become professionals and once they are professionals with money, they will probably take their business (when looking to buy houses, offices, etc.) to a bank that they already know and trust, i.e. the bank that supported them when they were students.

Unfortunately, my interaction with many of the banks in my city has left me fairly disappointed. Credit unions tend not to offer a professional student line of credit, which I suppose is understandable given that they are much smaller than most banks. Some banks offer professional student lines of credit, but with terms that are nowhere near their competitors. In my experience, a good professional student line of credit is at prime and does not need to be repaid until residency is complete. Make sure to read the fine print because some banks offer lines of credit that need to be repaid after two years of residency...which is fine if you are in a family practice residency, but you can get a better deal elsewhere if you are specializing in anything else.

Monday, June 14, 2010

Technology bottle necks, it's not brain surgery...except when it is.

I was observing the removal of an intraventricular brain tumour the other day when the importance of actually involving designers and users in the design process of, well, anything was confirmed.

The surgeons were removing a cyst from a patient's brain. They removed a portion of this patient's skull, cut through the dura, which is tissue between the brain and the skull, while avoiding all of the vital blood vessels along the way.

The next step was to place a tube into the patient's brain and insert a camera, laser, and foreceps through this tube and remove the tumour. Unfortunately, this next step almost didn't happen.

The problem? It could have been a complication with the earlier steps in the surgery, maybe they cut the wrong part of the skull, they could have accidently cut a vessel, maybe the child woke up during the surgery?! No, the problem was that the surgeons could not figure out how to set up the surgical equipment and combine the different parts.

Now, keep in mind, that this specific surgery wasn't a common one. The surgeons were not using this equipment regulary, but still, not being able to set up the equipment should not be the reason a surgery is delayed or stopped altogether. The problem here was that the equipment was probably designed by a group of engineers in an ivory tower somewhere without surgeons and designers providing input in the design process.

Technology should always be as easy to use as possible, especially when someone's life depends on it! Providing a complicated instruction manual is not a solution because surgeons are already excessively busy and most will not want to spend time reading a manual for a tool that they rarely use.

Just keep the design simple. Putting together the equipment should not be the toughest part of brain surgery!

Thursday, June 3, 2010

Speed of technology - it's difficult to take a programming hiatus

There was a point in time when I was very comfortable programming. I had finished my engineering degree and I had co-op and project experience in embedded and network programming. Next, I went to Microsoft and worked on the VB compiler there for a year. It was amazing how much more I learned about programming working at that company and more importantly, working with the people there. Being around a group of co-workers that were fanatically passionate about their work meant that I was exposed to new techniques, tools, and ideas that made me a much more efficient and talented programmer.

When I left Microsoft for medical school, I told myself that I would program on a semi-regular basis to make sure I retained what I had learned and stayed on top of the latest developments in the software industry. I was not under the delusion that I would have the time or energy to program regularly and become better, I just thought I could prevent regression.

After the first term of my first year, I threw together a very simple physics engine and created an incredibly basic simulation of the human immune system. This was a hacky project at best, but it was really the most I could do considering I actually wanted to take a break during my vacation.

Then in the summer after first year, I was using Excel to analyze data for a research project. I was able to dramatically reduce analysis time by writing VBA scripts to automate a lot of the grunt work. Again, this wasn't really programming, this was just scripting.

Now, as I'm looking at some of the most recent posts on programming blogs and forums, I realize that in two years there has been a lot of development in programming and the tools programmers use. Some of these changes are just fads or modified ideology (read: the flavour of the month), but many of them are true developments in the evolution of programming. Even though I currently feel like my programming knowledge is not up to date, I'm sure I can catch up if I dedicate some solid time to actually coding, but programming isn't really the most important skill for me to develop at this point in my career. With CaRMS (residency matching) coming around the corner, I should probably dedicate the time I would spend coding on, y'know, learning how to be a better doctor. It seems like the reality is that by the time programming will be a useful skill for me to have (in residency when I'm doing research is my best guess), I will probably have to re-learn a great deal of it. Fortunately, the most important skill a programmer can have is an analytical thought process...and that is something that doesn't degenerate (unless you have dementia).

The reality is...if you want to be a should code. Taking a break can be rejuvenating, but don't take it for too long because the industry will have moved along rapidly without you...

Tuesday, June 1, 2010

Multiple sclerosis breakthrough as researcher saves wife

Dr. Paolo Zamboni has been in the news several times in the past twelve months for his breakthrough discovery. He claims that patients with multiple sclerosis (MS) have been found to have clogged veins that are responsible for the symptoms of their disease. He bases this claim on his finding that most patients with MS have clogged veins, but their symptoms stop progressing and often become better after the veins have been unclogged. This is a breakthrough because currently we have been treating MS with immunosuppresive drugs that have had mixed results.

The article makes an error when it claims that Dr. Zamboni's findings contradict the current understanding that MS is an autoimmune disease. Hypothetically, the clogged veins prevent drainage of toxins which causes an inflammatory response in the brain. This inflammatory response causes the blood brain barrier to become permeable to immune cells, which is normally a good thing because it allows immune cells to enter the brain and attack the toxins or infection causing the inflammation. However, when these immune cells enter the brain constantly they may may instead wreak havoc on the myelin of the nerves (the current supported pathogenetic mechanism of MS is that the immune cells attack the myelin of the nerves). This theory, which is also mentioned in the article (so it really doesn't make sense that the article claims the findings oppose the belief that MS is an autoimmune disease), allows both the current understanding of MS and Dr. Zamboni's findings to co-exist peacefully.

An interesting subplot in this story is that Dr. Zamboni was motivated to perform this research because his wife was suffering from MS. He studied the current research on MS thoroughly and realized that patients consistently had increased iron deposits around the veins that drain blood from the brain. Most physicians and researchers attributed this to the constant autoimmune reactions associated with MS, but Dr. Zamboni thought that it might be more significant. After measuring the blood flow of the venous drainage of MS patients and realizing that they were significantly lower than healthy people...he developed his new therapy...

I bet that he won't be yelled at if he forgets to put his clothes in the hamper, at least not for a couple of months...

Monday, May 31, 2010

Work Life balance in med school

Work life balance is an important issue for anyone and everyone (with the obvious exception of those who don't have to work to afford a living...or conversely, those who are dead). However, the general impression that most of society has about med students is that the balance is tipped heavily towards the "work" side.

Before I share my thoughts on work life balance as a med student, I want to make a disclaimer: this is my perspective obvious disclaimer maybe, but a very important one. I say this because for most of my post high-school life I have been warned about the horrible work life disbalance associated with the decisions that I was making. In high school, my teachers warned me that university, particularly engineering, involves consistent all nighters and long days hunched over books in the library. These teachers were clearly unaware of the digital revolution that would allow me to be hunched over a monitor in my home instead. Regardless, they were very wrong as I had an amazing time at university. The balance was tipped far to the life side, I did not study that much and I only ever pulled one all nighter (building a robot that would seek magnetic sources) while still being very successful. This was similar for most of the people I met in university. Sure, there were different periods where we didn't go out as much, particularly during exam season, but for the most part, most of us had a great time through university. I say most because there were certainly some individuals who had to work harder to understand the material taught in lecture, which resulted in them spending more time studying. I certainly respect these people for their dedication and perseverance, but they were definitely in the minority.

Next, when I finished my undergraduate training and I was offered a job at Microsoft, people were quick to tell me stories they heard about their friend's uncle's dog-walker's brother who was worked hard at Microsoft and never saw natural sunlight, much less his family. This was a particularly terrifying prospect for me because I am fairly opposed to developing osteomalacia. However, during my time at Microsoft, I had an amazing work life balance. I worked hard for 8-10 hours a day, but I had my weekends and evenings free and I was well compensated. I was able to manage this balance while still being successful at work and even being promoted at the end of my year there. Of course, in this situation again, there were individuals who were working much harder that I was...hacking away in front of their monitor all day, but they were the minority from what I saw. Keep in mind that I was only really exposed to one team at Microsoft, other divisions may have been run differently. Also, I was a junior employee and only there for a year. If I wanted to work my way up the ranks, I may have later had to work longer hours, I have no idea.

If you got anything from the above stories, I hope it was that you shouldn't whole heartedly take anyone's opinion about the work life balance of anything. My experience through med school thus far is my experience and every other med student has a slightly or very different set of experiences.

I have been able to strike an excellent balance between school and life throughout the first two years of med school. I go out at least twice a week with friends/family; I play soccer competitively and I can make it to two practices and two game per week; and I'm interested in research so I do that on the side, in moderation, throughout the year. I also have an awesome girlfriend, which I normally wouldn't mention, but I think it is relevant here because relationships do require a reasonable time commitment. I'm able to do this and still stay on top of the material being taught. However, in order to maintain this balance, I have to be more disciplined than I ever have been before. I barely ever procrastinate and I have made some sacrifices. I didn't think I could manage playing both soccer and hockey competitively, so I gave up hockey. I also don't program at all during the school year, which is a skill that I want to maintain, but I realize that it isn't necessary for my immediate needs so it has been put on hold. Again, my experience is not unique, I have many classmates that would say the same about their work life balance. However, with regards to life in med school, I'm not sure if I would say that the outright majority of students share this kind of balance. There are a fair number of my classmates that spend a significant amount of time at the library throughout the year and they are constantly studying. I personally believe that for the most part, they do not have to study that hard, but exam anxiety is driving them to study hard from the very beginning.

However, during the month before exams, work life balance is out the window. A month before the exams begin, I'm either in classes or studying. I'll go out once a week and go to 2 soccer practices and 1 game a week, but that is it. I'm basically working 14 hours, 7 days a week. There are times when I really do feel like a prisoner in my room. Unfortunately, we have so much material to learn that we have no other choice. Despite what I said earlier, I feel comfortable saying that all med students will agree about this kind of work life imbalance during exams.

Now that I'm done 2nd year, I'm hearing horror stories about how busy I'll be in 3rd year. Should I believe them?

Sunday, May 30, 2010

New Respiratory Illness

I'm a little late on this one because I was busy with exams, but here is an article talking about a possibly new respiratory illness that seems to be contagious.

So be careful if you live near Glengarry hospital and you are thinking about going in!

Saturday, May 29, 2010

Pre-Clinical Years....Done

Most medical schools in North America are 4 year programs. The first two years focus on pre-clinical, lecture based theory. The final two years are practical, hospital based training where we actually learn how to practice medicine.

Being lecture based, the first two years are very similar to undergraduate years...just a lot more work, a LOT. As an undergrad, I usually had 6 or 7 final exams per term, which is more than most undergrads because I was in engineering. In medicine, I had 10 or 11 final exams per term. On top of that, each exam had considerably more material than I ever dealt with in undergrad. So, like I said, med school is a LOT of work.

Looking back, I have definitely learned a lot in the past two years. Not just about the science of medicine, but also interacting with patients. As physicians we have a limited amount of time (often only 10 minutes) to talk to patients when they are most vulnerable. Comforting and reassuring a patient with that kind of time restriction is definitely a skill that takes time to learn and experience to perfect.

I'm interested in seeing how things progress in the next two years, when we get to put theory into practice...

Wednesday, April 14, 2010

Why does massage or movement relieve pain?

Have you ever stubbed your toe and then grabbed or massaged your foot to relieve the pain? Or have you ever seen someone hit their own thumb while they were using a hammer and wondered why they would then shake their hand to make the pain go away?

If anything, these actions are counterintuitive methods of pain relief. If you just damaged a body part, wouldn't putting pressure on it or moving it around cause more damage?

Turns out that a lot our behaviour that appears counterintuitive at first glance makes sense once you finally understand the mechanics at work. In this case, when you hit your hand, foot, or any body part, your pain nerves from that body part send a signal through your spinal cord into your brain. This signal is what makes you think "ouch". There are other nerves that also originate in this same body part that send signals when the body part is being touched or moved. When these nerves are activated they temporarily attenuate or reduce the signal being sent from the pain nerves to the brain, giving you temporary pain relief.

Of course, this phenomenon doesn't work in every scenario... if you ever have your arm sawed off... it will hurt, a lot, no matter how hard you shake it...

Tuesday, April 6, 2010

Does Tiger Wood's platelet-rich plasma transfusion therapy work?

Tiger Woods, and apparently many other athletes, have tried platelet-rich plasma transfusion to accelerate their bodies' natural healing process to get themselves fit to play after injury sooner than normal. Platelet-rich plasma transfusion is used to heal tendon injuries, which are very common in both professional and amateur sports. The treatment involves collecting a patient's blood and removing his red and white blood cells so that only the plasma remains. This plasma, which is injected into the injury site, contains platelets, which release platelet derived growth factor (PDGF), which plays an important role in the natural healing process.

One of the reasons tendon injuries usually heal slowly is because they do not receive much blood; thus, very few platelets and PDGF ever reach the injured tendon. Injecting platelets into the injured tendon augments platelet delivery to the damaged tissue.

This article is a great introduction to platelet-rich plasma transfusion and also contains an interview with the physician who used it to treat Tiger Woods.

An important thing to note from the article is that we have not properly studied the effects of this therapy; thus, we cannot truly be sure that it actually works, nor can we be sure that it doesn't lead to some additional harm years after the injection is given. The article agrees that we need more research before we can state that platelet-rich plasma is a reasonable and effective treatment option for chronic tendon injuries.

Sunday, March 28, 2010

Common sense battles bipartisan politics

Obama's monumental health insurance reform finally made it into US law this past week. Unfortunately, this victory for Obama (and the American people, in my opinion) will be tainted by political strategizing.

Before the bill was finalized, the senate was given the opportunity to put forth amendments to the bill. These amendments would then be voted on by the senate and if any amendments won a majority vote, they would be instated into the bill. However, if any amendments were instated into the bill, this would mean the bill was changed (obviously) and that the congress would have to vote on this changed bill once again. Thus, the Republicans, who have realized that they cannot stop this bill from becoming law, decided to make numerous amendments to stall the bill in bureaucracy. However, since the Democrats have a majority number of seats in the senate, they could form a united front and prevent any amendments from winning a majority vote.

One amendment put forth by Senator Coburn, who is a physician himself, was that the bill should bar insurance coverage of erectile dysfunction drugs for sex offenders. A majority of the Democrat senators voted against this amendment. I'm guessing that they voted against the amendment because they wanted to avoid Republican stall tactics and not because they believe sex offenders should have erectile dysfunction drugs covered. Thus, an amendment that should have been made to the bill was not. You can bet that this political strategizing by the Democrats will result in the Republicans using the votes against the amendment as a smear campaign during the next election, but more payers will be paying for erectile dysfunction drugs for sex offenders.

It is unfortunate when politics gets in the way.

Sunday, March 21, 2010

Why do you get a black eye after you break your nose?

If you get punched in the arm hard enough, you will develop a hematoma (bruise) localized to the area of trauma. So why is it that you can get a black eye after breaking your nose?

When you break your nose, you damage adjacent blood vessels that release blood into the surrounding area. This is the same mechanism that results in a localized hematoma. However, the skin on your face has a looser layer of connective tissue underneath, which makes it softer than your skin elsewhere. The blood released from your broken nose can flow more easily through this loose connective tissue and often pools beneath the eyes. This blood then oxidizes, darkening and resulting in a black eye.

Sunday, March 14, 2010

Why does yawning unplug your ears?

Your middle ear is an air tight cavity that is isolated from your outer ear (and the outside world) by your tympanic membrane. Your middle ear does connect to the outside world via your eustachian tube, which joins your middle ear to the back of your nose (actually to your nasopharynx). This tube is normally collapsed, allowing your middle ear to remain air tight, but it does open when you yawn or swallow.

The reason your ears get "plugged" when you are in an ascending or descending airplane is because a pressure differential forms between your middle ear and the outside world. When you yawn, your eustachian tube opens and this allows the pressure between the two to equalize.

And that is why yawning "pops" your ears when they are plugged.

Tuesday, March 9, 2010

Why does the flu cause aches and pains?

Nobody wants to catch the flu. Millions of people get vaccinated against the latest flu strains every year because they don't want to suffer through the misery the flu brings. One very common symptom that most patients with the flu complain about is deep body aches and pains.

If you think about the life cycle of a flu infection, it is actually surprising that the influenza virus (the virus that causes the flu), which primarily lives in your respiratory tract, can cause pain throughout your entire body. In reality, the influenza virus itself is not directly responsible for this pain. The pain occurs because your immune system releases inflammatory chemicals (cytokines) while fighting the influenza infection. Some of these cytokines cause your own body's cells to produce an enzyme called cox-2, which creates chemicals called prostaglandins. Prostaglandins have many functions, but one is to sensitize your nerves to pain...causing that aching sensation that comes with the flu.

At first glance, you might ask why would our own immune system hurt us. That's a good question and no one really knows the answer. I suspect that these aches and pains may have evolved to force us to rest when we are sick, so maybe our immune system is hurting us so that it can help us by fighting off the infection faster?

How to give a good lecture: state your objectives

Lecturing is a skill that is in short supply. Unfortunately, university policies don't prioritize lecturing when hiring professors. Most professors are offered positions at universities because of their talent as researchers; however, good research does not imply competent teaching. This may not be true in all faculties, but it is certainly the case in science, engineering, and medicine.

University policy often dictates that professors must spend a certain number of hours lecturing students. I do certainly see the validity in the policy; it would be ridiculous if you had a world renown professor working at a university and none of the students were given a chance to learn from him/her. However, forcing professors to lecture when they are astonishingly bad at it is a recipe for disaster.

In medicine, we have had many lecturers, some good, some bad, some terrible. There are often many common flaws that are ruinous to any lecture and one of them is not starting off the presentation with a slide stating the lecture's objectives.

We need to know what we are supposed to learn from the talk before you start lecturing. If we don't, we can't filter the vital information from the extraneous or esoteric. If we can't filter out the unnecessary, we are overwhelmed with the overload of information and it all becomes white noise. Remember, in medicine, we have a lot of information that we need to absorb...if you don't help us prioritize, we will resent you for it and not learn properly.

It really isn't hard, just give us bullet points on the information in your lecture that you think is absolutely essential for us to retain. Then, even if you are disorganized and jumping around from topic to topic (which you shouldn't be doing!), we know when we can relax and when we absolutely have to take the time to note specific details you may have forgot to put in our note package.

Thursday, March 4, 2010

Mental Illness and the Resume Gap

Mental illness is probably one of the challenging diseases to live with. Yes, it is a disease; if you have mental illness, you are sick, no different than being sick because you have leukemia or hepatitis. However, if you had leukemia or hepatitis, people would acknowledge that you were unwell and probably rally around you for support. Unfortunately, society's stigmatization of mental illness results in many mentally ill people being shunned by their closes friends and family.

Mental illness is also very challenging to treat, partially because we do not fully understand the physiology behind the disease and it is difficult to fix something when you do not know how it is broken, but also because mentally ill patients do not often realize that they are sick. Mental illness can distort the way your brain interprets reality; thus, mentally ill patients may hallucinate without realizing that their hallucinations are not real. Many of these patients are unwilling to take anti-psychotic medication because they do not believe that they are sick and they do not want medication to alter their brain chemistry, which they think is healthy/normal.

Patients who have had mental illness in the past can also face many problems once they have recovered from the disease. Recently, a patient made a presentation to our class about her battle with mental illness and mentioned how difficult it was for her to find employment after her illness was finally being adequately treated.

She became mentally ill and refused to take medication for several years because she believed that her hallucinations were based in reality and thought that medication would needlessly cloud her brain. She basically believed that she was healthy and the medication she was being asked to take to treat her mental illness would, in fact, make her mentally ill. During the time she was mentally ill, her hallucinations prevented her from being able to keep a job. After years of being untreated, her husband finally convinced her to take medication. Shortly after that, her hallucinations stopped occurring and she was able to function normally again.

This woman was ready to get her life back and, for her, a major part of getting her life back included returning to the work force. Fortunately, in Canada, we have laws that prevent employers from asking prospective employees if they are mentally ill (actually the law prevents them from asking any health related questions). Unfortunately, there was a huge, unexplained gap of unemployment in this patient's resume which spanned several years. Thus, she would be forced to either lie or tell the interviewer that she was ill for an extended period of time. How many employers are going to hire a person who was chronically ill for several years? Now, if she was completely honest and told them about her mental illness, how many would hire her then?

This resume gap is a huge problem for patients who were once mentally ill and are now healthy and trying to live a normal life. Finding work with an unexplained period of unemployment is incredibly challenging. This results in many of these patients being forced to work in the mental health sector where the stigma around mental health is obviously significantly lower. In larger cities, this may be a reasonable means of reintroducing mentally ill patients into the work force. However, in smaller cities, there may not be a mental health team, or the teams may be very small and not looking for new members. How are mentally ill patients in these cities or towns supposed to return to the work force?

This is a major problem because meaningful employment is an important aspect of many people's lives in terms of determining their self-worth. People who are returning from mental illness often need to feel productive. If they do not, it is incredibly easy for them to slip into depression, for which they already have an increased susceptibility.

Until the stigma around mental illness subsides, this resume gap is a small issue that will be causing huge problems...

Saturday, February 20, 2010

Prevention vs. Treatment

The global recession was a horrific experience for many people across the planet. The realization that spending beyond your means is a dangerous game with dire consequences was a harsh return to reality for many people throughout the developed world.

Now, more than ever, if I suggested that your current spending was putting you deeper and deeper into a debt that you would have to spend the rest of your life repaying, you would probably rush to your financial planner and reorganize your budget.

So why are obesity rates across the developed world increasing? Why are we so comfortable with the idea of eating ourselves to death?

If most would agree that it is better to stay out of debt than to spend a lifetime repaying debt, why do we not see that overeating is analagous to going into debt and that that chronic illness like diabetes and ischemic heart disease from atherosclerosis is analagous to spending a lifetime repaying that debt?

It is because when it comes to their health, most people lack foresight. Many feel that they can just take medication when they are sick. They don't care to exercise and eat healthy so that they won't need the medication in the first place.

In many ways I understand this thought process. I might even support this behaviour if we actually had pills that would cure disease with no costly or chronic side effects. Unfortunately, that is not the scenario that is available to us. Metformin and glyburide do treat diabetes, but they are not a cure. Diabetics are still chronically ill and face a decreased quality of life despite the availability of diabetic medication, which they will have to take for the rest of their lives. As for atherosclerosis, once your arteries are clogged with fat, your heart will not function to its full potential...ever, regardless of how much nitro you take.

Ignoring prevention in favour of therapy is not solely the fault of patients (it is still mostly their fault; after all, you should take responsibility for your own body and health!). Physicians tend to focus on treatment; they spend significantly more time with the already sick patient than they do with the healthy patient who will be sick in the future if nothing is done now.

I attribute this phyician focus on treatment partially to physician training and mostly to the health care system. Medical school focuses on teaching us how to heal the sick much more than it focusses on how to prevent the healthy from becoming sick. This may be unavoidable because you absolutely need to ensure that your doctors know how to heal the sick and there are so many diseases out there it already takes at least 6 years of training to become competent enough to practice medicine. Does that mean we need another set of health care professionals working on prevention? Or maybe we should have a new specialty physician who focusses on prevention?

The health care system has a role to play in physician interaction with patients because MSP, the government organization that pays physicians for their services, does not provide much financial compensation for preventative treatment. I don't want to get into an argument about how much doctors should/should not care about finances when they are the ones entrusted to care for the sick, but realize that human nature will motivate anyone to act in a manner that maximizes their profit to effort ratio. If we want to see doctors spending more time on prevention with patients, maybe the health care system should value prevention more.

In the end though, as I have already said, you can't blame your doctor or your health care system for making you fat if you are the one eating poorly when you know better... and in this country, most people do know better.

Thursday, February 11, 2010

Looking for a kidney? Check the pelvis

I was working with a family doctor who asked me to go in and do a cardiac and abdomenal physical exam on a patient who had "interesting findings". He told me to make sure I palpated the kidneys. I was also told that the history had already been taken so I didn't have to bother with that.

I began with a cardiac exam. The only significant finding was a grade 2/6 (very quiet) systolic murmur. I figured the doctor asked me to do a cardiac exam on this patient because he wanted me to find that murmur, so I was happy to find it so quickly. I then continued with the rest of the exam.

I began the abdomenal exam thinking this patient must have a kidney tumour or some kind of kidney inflammation because the doctor made a point of asking me to palpate the kidneys. Normally you cannot feel a kidney on an abdomenal exam because they are surrounded by fat and muscle. The only time you can feel a kidney is when it is pathologically enlarged, or so I thought...

I was trying to palpate the kidneys for five minutes but I couldn't feel anything. Not being able to palpate enlarged kidneys may be expected in a fatter patient, but this patient was relatively thin. Finally, the patient, clearly seeing that I was struggling, began laughing at me. He decided to put me out of my misery and pulled his shorts down past his groin revealing an abnormal bump in his pelvic region...his kidney.

Turns out this patient had bilateral pyelonephritis that ended up destroying his kidneys, so he had to have a transplant. Often with kidney transplants the old kidneys are not removed; instead, their ureters (tubes connecting them to the bladder) are cut and ligated to the new, transplanted kidney, which is placed in an empty space in the pelvis.

Tuesday, February 9, 2010

Open Sourcing Research Software

An article in the Guardian calls for researchers to open source (release to the public) the computer code they use in their research.

As a former programmer, I think that this is a great idea. It is surprisingly easy for even the most talented programmer to make simple mistakes in their code that cause their program to provide erroneous, misleading results. Asking for the computer code to be released to the public will allow skeptics and peer reviewers the chance to criticize how data was analyzed. This criticism can catch mistakes and lead to more powerful experiments, but will researchers have too much ego to release their code?

In industry, programming errors are caught by demanding that programmers test their own code and then having a team of testers test the code. Unfortunately, the luxury of a robust testing team is not afforded to many researchers. Also, it is hard to expect, for example, a biology researcher, who is a self taught programmer, to create a detailed and powerful test harness for his software.

I would actually be surprised to see the open sourcing of research code become a common practice because I think many inexperienced programmers who program for research will be too embarrassed to release their code in a domain where professional software developers are able to criticize their work. I blame this on the programming profession rather than the researchers. Programmers are notorious for being outspoken and rude when commenting on amateur code. Another barrier to this practice is that code that is being released to the public domain needs to be readable/understandable, instead of being readable to only the programmer who wrote the code. This preparation will add time to the already busy schedules of most researchers.

Unfortunately, I suspect this will be one of those great ideas that many support, but few practice.

Thursday, February 4, 2010

Lithium perscriptions are not supplements

No, I cannot give you a prescription for lithium.


Because lithium is used to treat bipolar disorder and you do not have bipolar disorder. I understand that your naturopath tested your hair for trace elements and his tests show that you have low levels of lithium; however, you just said you didn't have any health complaints.

You want to try 5 mg of lithium per day, but the smallest tablets I can find are 100 mg. Are you really going to cut this tablet into 20 pieces? Even if you did, if anything happens to you, like thyrotoxicosis leading to hypothyroidism (a side effect of lithium)... how am I going to explain that I gave a perfectly healthy patient, who was not bipolar, a prescription for lithium?

Saturday, January 23, 2010

Disabling proquota.exe in XP Home Edition

Windows is not a normal topic of discussion here, but I struggled to find any information to help me with this problem, so I thought I'd post my solution.

After running combofix to clean up some viruses, proquota.exe was found to be missing from my system32 folder and combofix kindly reinstalled it. Unfortunatly, proquota.exe limits the profile size of user accounts, meaning that you can only store so much (10 MB in my case) on your profile (which includes your Desktop, MyDocuments folders, etc.). As a med student, I have a LOT of documents that I like to store in MyDocuments, so this was unacceptable.

If you have XP Pro or Server2003 you can easily find instructions to disable proquota; however, if you have XP Home, you're more or less hooped.

To disable proquota I had to make the following change to my registry (remember, hacking your registry is ALWAYS risky if you don't know what you are doing):

First, go to Start->run and type in "regedit".

Then in the Registry Editor, go to HKEY_CURRENT_USER->Software->Microsoft->Windows->CurrentVersion->Policies->System

Finally, double-click on EnableProfileQuota and set it to 0.

Restart your computer, and proquota will not bother you again.

Monday, January 11, 2010

Engineering vs. Medicine

When I was accepted into medical school, many people congratulated me with a "dude, you're leaving a good job to go back to school, med school's tough, why would you bother?!"

Friends who had graduated from engineering like I did responded a little differently, "dude, you're leaving a good job to go back to school, oh well, med school can't be that much tougher than engineering."

Having been through 1.5 years of medicine, I can certainly say that the engineers were very wrong. Conceptually, I don't think any single topic covered thus far in my medical education is any more difficult than the topics covered in electrical engineering. In fact, I would argue that courses on quantum mechanics and nanotechnology were probably more difficult to understand than anything I've been taught in med school. However, the major difference is volume of information. A single week in med school seems like at least half of an undergrad course. We have to read, understand, and memorize a ridiculous amount of information.

Which brings me to another difference between engineering and medicine. Engineering required very little memorization. For the most part, in engineering, you only have to memorize first principles and then you can usually derive any other equation you need. There is no way to derive the cranial nerves and their functions, nor is there any way to derive the different pathologies responsible for papulosquamous eruptions...there's no way around it, you have to memorize in medicine!

The workload in engineering is above and beyond that seen in most other university programs; however, the workload is much, much greater in medicine than even engineering. The only consolation med students have is that most schools grade on a Pass/Fail system, as opposed to a letter grade system. So for the most part,in med school, getting a 60% is as good as getting a 90% on an exam (not from the patient's point of view obviously), you don't have to worry about getting A's anymore.

The last difference that became very apparent to me last month is the difference in exams. My engineering exams were almost entirely math based; I don't remember ever seeing multiple choice on any of my exams. Med exams are entirely multiple choice, and there are a LOT more questions asked, which makes sense considering the significantly greater volume of information taught. After completing an engineering exam, most students have a good idea about how they did in that exam. After completing a med exam, most students have no clue how they did in that exam! A number of my classmates have seriously believed that they failed an exam, only to later find out that they aced it.

Saturday, January 2, 2010

Why Nerds Wear Glasses

Society and pop culture paint a picture of the smartest, most intelligent people (nerds) wearing thick glasses and rocking pocket protectors. Admittedly, I would normally advise against buying into stereotypes, but there may actually be some validity to this particular generalization.

Studies looking at myopia (nearsightedness) have found that the more educated a person is, the more likely they are to have myopia [1, 2]. Another study showed a correlation between myopia and time spent reading in children. This correlation may indicate that "close work", including reading or any other activity that requires the eyes to focus on some nearby object, results in myopia. Of course, correlation does not necessarily indicate causation, but the theory reconciles the two aforementioned findings nicely. If increased reading causes myopia, it is not surprising that a higher degree of education is associated with an increased likelihood of myopia as more educated people probably tend to read more.

Now, why do nerds wear pocket protectors?