Medical School 2020, Year 2, Week 19

From our anonymous insider…

A reproductive endocrinologist begins Monday morning with a one-hour lecture on infertility. She explains that 15 percent of couples experience infertility, defined as more than one year of unprotected intercourse without conception. Fecundability, the probability of achieving pregnancy in a single menstrual cycle, should be about 25 percent. Infertility is on the rise in America: “More and more of my practice is managing PCOS [Polycystic Ovarian Syndrome, driven by obesity].”

An obstetrician finishes the day with three hours of lectures (four hours total for the day, so we were done at noon). “Spontaneous abortions occur in 20 percent of all pregnancies,” she notes. “Most people do not even realize fertilization has occurred because the abortion occurs in the first trimester. At eight weeks of age with heart sounds, there is less than 5 percent risk of spontaneous abortion.” The risk of miscarriage doubles every 5 years after the age of 35. (My female classmates, especially those who didn’t come straight from college, have been talking about this since M1. They may be residents well into their 30s so when do they have children?)

The OB lecture covers the placenta, the organ that exchanges oxygen, nutrients and waste between the maternal and fetal circulation. “The placenta regulates all the blood flow to the baby. If you lined 100 placentas up, I could tell you exactly which mother was smoking or using cocaine. Preeclampsia, eclampsia and HELPP [Hemolysis, elevated liver enzymes, low platelet count syndrome] syndrome all involve issues with the placenta.” We discussed placenta previa, where the placenta partially overlies the cervix. Cesarean section is performed at 39 weeks because of the increased risk of hemorrhage prior to delivery. “If a third trimester pregnant woman presents for painless vaginal bleeding, DO NOT perform a vaginal exam. During my residency, I saw another resident stick his finger right through the placenta causing hemorrhage.” [Editor: maybe don’t go to a teaching hospital?]

The rest of the week is devoted to three hours of daily lectures on nephrology. A 34-year-old soft-spoken nephrologist begins with a one-hour review of last year’s kidney physiology. The block director, a PhD in molecular biology, is charged with ensuring we get our LCME-mandated 10-minute break after 50 minutes of class. During the break female classmates discuss how good-looking the lecturer is, emphasizing his fitness and broad shoulders.

Pinterest Penelope (recently broken up from her M3 boyfriend): “I love younger physicians. They understand what we are going through. Our fondness of First-Aid, our cluelessness about residency, our anxiety about Step I. Older physicians live in a different world.”

Lecture continues with two hours on acute kidney injury (AKI). Every minute, 100 mL bleeds out of our capillaries through the glomerulus, a biological filter, into the kidney tubule system and finally the bladder. Over 99 percent of the filtered volume is reabsorbed through active transport of solutes creating an osmotic gradient for fluid reabsorption to maintain the body’s electrolyte and fluid balance. Kidney aging, drugs (e.g., antibiotics, and NSAIDs), and autoimmune diseases decrease the summed rate of filtration, glomerular filtration rate (GFR), and the proportion of electrolyte reabsorption. The nephrologist explains: “You lose about ten milliliters GFR every ten years after the age of 30. As long as you do not have a comorbidity, you will never lose enough to confer disease. The problem is most Americans will develop a comorbidity.”

Kidney injury is divided into several categories:

  1. Acute versus Chronic
  2. Location of insult: pre-renal (e.g., decreased blood flow), post-renal (e.g., ureter obstruction) or intra renal (e.g., inflammation of tubule system)
  3. Urine character: Nephrotic (protein wasting) versus Nephritic (red blood cell wasting)

Our patient case: 4-year old Baby Nora and her family hosted a family reunion cookout filled with beer, burgers and brats. Three days later, Nora develops a fever, abdominal pain, vomiting, and diarrhea. She is taken to the ED that evening, given IV fluids for dehydration and discharged home. The following day, Nora is brought back to the ED after her family notices bloody diarrhea.

On physical exam, Nora appears lethargic. She has tachycardia (high heart rate), tachypnea (fast breathing), a 101 degree fever, and hypotension (low blood pressure, 80/60). Given the bloody diarrhea and lack of symptom improvement, a “rainbow” is drawn. The tube for each test has a different color and when EM physicians are stumped, each tube is filled with blood. CMP (Complete Metabolic Panel) shows hyponatremia (decreased blood sodium) and uremia (elevated blood urea). ABG (arterial blood gas) reveals a primary anion-gap metabolic acidosis with respiratory compensation. CBC (complete blood count) shows leukocytosis (elevated white blood cells), thrombocytopenia (low platelets) and anemia (low red blood cells). Peripheral blood smear reveals the presence of schizoschites, suggestive of a vasculopathy. Urinalysis shows the abnormal presence of protein and red blood cells.

Her doctors are concerned about hemolytic uremic syndrome (HUS), the most common cause of acute kidney injury in children. The disease is caused by ingestion of Shiga toxin from E. coli O157H7, which typically accumulates in colonized food rather than being produced by bacteria that have colonized the gut. Also, if there is an infection, killing the bacteria all at once can release a flood of Shiga toxin. Thus antibiotics are not started and doctors will rely on the patient’s immune system to kill any remaining bacteria. Shiga toxin damages small blood vessels and causes formation of small blood clots (microthrombi). These blood clots shear red blood cells creating the characteristic schiztoschites seen on a peripheral blood smear.

Nora’s urine output continues to decline, and hemodialysis is started and continued for five days until her creatinine levels improve. Creatinine is a muscle protein product excreted by the kidneys at a constant rate used to measure kidney function. She requires one unit (300 mL) of packed red blood cells to maintain her hemoglobin above 7.5.

Nora gradually recovered during a 10-day hospital stay and, now age 9, does not remember the incident. Her parents reflected how scary the experience was. “I was furious at the doctor who sent us home when we brought her the first time. After the emotions simmered down, I have forgiven her. There wasn’t any sign that it was more serious than just a typical food poisoning.”

Nora’s kidney function, as measured by GFR, is back to normal, placing her among the lucky 70 percent who recovery fully.

Our two hour ethics workshop focuses on disability. We read Enforcing Normalcy: Disability, Deafness, and the Body by Lennard Davis, “a nationally and internationally known American specialist in disability studies [an academic discipline]” and English professor at University of Illinois at Chicago (Wikipedia). Our ethics professor: “He uses the Marxist perspective. The disabled population is oppressed, and thus must be be given justice. Davis argues as long as society uses an ableist mentality, we will be unable to correct the injustice. He exaggerates slightly, but within the pieces are an immense amount of insight into the human experience.” From the 1995 book:

When I talk about culturally engaged topics like the novel or the body I can count on a full house of spectators, but if I include the term disability in the title of my talk or a session the numbers drop radically. … our goal should be to help “normal” people to see the quotation marks around their assumed state. The fact is that disability as a topic is under-theorized — a remarkable fact for this day when smoking, eating a peach, or using a bodily orifice are hyper-theorized.  Because of this under-theorization, which is largely a consequence of the heavy control of the subject by medical and psychosocial experts, the general population does not understand the connection between disability and the status quo in the way many people now understand the connection between race and/or gender and contemporary structures of power.

… The category itself is an extraordinarily unstable one. There is a way in which its existence is a product of the very forces that people with disabilities may wish to undo. As coded terms to signify skin color — black, African-American, Negro, colorized — are largely produced by a society that fails to characterize ‘white” as a hue rather than an ideal, so too the categories “disabled”, “handicapped” “impaired” are products of a society invested in denying the variability of the body.

In the process of disabling people with disabilities, ableist society creates the absolute category of disability. ‘Normal’ people tend to think of ‘the disabled’ as the deaf, the blind, the orthopedically impaired, the mentally retarded. But the fact is that disability includes, according to the Rehabilitation Act of 1973, those who are regarded as having a limitation or interference with daily life activities such as hearing, speaking, seeing, walking, moving, thinking, breathing, and learning. Under this definition, one now has to include people with invisible impairments such as arthritis, diabetes, epilepsy, muscular dystrophy, cystic fibrosis, multiple sclerosis, heart and respiratory problems, cancer, developmental disabilities, dyslexia, AIDS, and so on.

…  In ‘talking’ with Deaf colleges on e-mail particularly those whom I have never ‘seen’, I often ‘forget’ that my interlocular is deaf. Recently, in planning to attend a session at the Modern Language Association on disability, I received and sent a welter of messages on email to a number of people involved. I had no way of knowing which of these people was disabled, or in which way. When speaking on the telephone with a person who uses a wheelchair, I have no way of knowing if that person is unable to walk.

When the ethics professor was busy with another small group, Geezer Greg said, “I could have learned more by watching Curb Your Enthusiasm. Larry David calls a mechanic to bring his car in. When he brings his car in and meets the mechanic in person, Larry is surprised to find that the mechanic is black: ‘You did not sound like it on the phone.’.”

Persevering Pete: “I am not sure what Davis is arguing. On one hand he does not want people to consider disabled individuals as a separate group, but he wants more financial assistance for the disabled.”

Luke: “Where does Davis draw the line on collecting disability checks? Am I on the spectrum?” Greg: “That’s a Curb Your Enthusiasm episode also! The girlfriend claims her son is on the Asperger’s spectrum, but Larry David thinks he is just a spoiled brat.” (The wife sues for divorce during Season 8, taking the house and putting Larry back on the dating market.)

The ethics professor did not mention the financial aspects of being classified as disabled, nor that medical doctors are now the gatekeepers for whether or not an American can get aspect to disability payments (see “How Americans Game the $200 Billion-a-Year ‘Disability-Industrial Complex'” (Forbes)), nor that some doctors earn 100 percent of their income as disability gatekeepers. This is something that Hippocrates probably could not have imagined.

Our week concludes with the Genital Teaching Assistants (GTA) teaching us how to perform the scrotal, penis, digital rectal exam, pelvic, and breast exams. The family medicine physician coordinating the workshop introduced this opportunity: “These are professionals that travel the country teaching these exam skills. Ask them any questions you have, this is their job. And let me tell you, they are good and they are very expensive — largest item in our budget, I am talking thousands of dollars — so we are partnering with internal medicine residents to bring them.” Gigolo Giorgio learned that the female GTAs make $90 per student ($70 for vaginal exams, $20 for breast exam) or over $1,000 (3 groups of 4) in the afternoon workshop. The national standard seems to be that male GTAs are paid less, but so far there have been no demands for equal pay. Luke: “How much would you have to get paid to do that?” A few of the guys responded: “No questions asked, sign me up.” No female classmates answered.

We are divided into teams of four and rotate through a male GTA for 1.5 hours and a female GTA for 2 hours. My group happens to be all male. The 35-year-old male GTA is a married family medicine resident with two sons who has been doing the GTA program as a side job for 3 years. Patricular Patrick leads the way beginning with the scrotal exam. We individually practice each step of the exam. The GTA is extremely helpful, drawing on his medical experience to emphasize certain pathologies to look out for at each step of the scrotal and penile exam. The digital rectal exam is last. As Particular Patrick is searching for the prostate, the GTA adds, “My right prostate lobe is slightly larger than the left.” There is a 15-minute break before the female GTA session. Pinterest Penelope was enthusiastic about having felt a direct hernia in a “65-year-old geezer,” but noted the “shriveled balls.”

Our female session is with a 25-year-old GTA with two years of experience. She uses a mirror to help guide each of us through the exam as we struggle to handle the speculum to locate the cervix and to palpate the ovaries using the bimanual technique. She emphasizes, in an Eastern European accent, never to close the speculum until partially retracted to prevent closure on the sensitive cervix. We took longer than expected, so only one of us is allowed to perform the uterorectal exam. Ambitious Al quickly volunteers with no shame. Gigolo Giorgio was disappointed he could not practice it. This snafu apparently happened in other groups as well, and a few students (not Giorgio to my knowledge) complained how this asymmetric experience was unfair to those who did not get to perform the rectouterine exam. The family medicine physician apologized.

Jane: “This experience hit a lot of us. It seemed like everyone respects what happened, it’s a kind of a milestone.” (Jane might not have heard a few wags joking about the scrotal, bimanual, and uterorectal “shocker” exam.) The Family Medicine instructor comments, “I am glad no one fainted. One gentleman last year fainted while examining the male GTA.”  Two (male) students became light-headed during both the rectal (male) and bimanual (female) exam, although no one fainted.

Jane and I ate dinner with her mother, learning that she loaned Jane’s sister just under $10,000 to pay off a Lowe’s loan for repairs on the ex-boyfriend’s house (see Week 14). Solvent thanks to this and Jane’s loan of $5,000 to pay off her credit card debt, the sister has recently gotten back together with the ex-boyfriend. “Well, I feel like an idiot!” said Jane’s mom, not a fan of this boyfriend. “I keep thinking if she still had the 10k ‘L’ [for Loser] hanging over his head, they would never have gotten back together.”

It is a week before Thanksgiving and Type-A Anita is hosting the class potluck Friendsgiving on Saturday afternoon.  Anita’s board game collection includes The Cat Game and Trump: The Game, a gift during the election night party. “Still too soon to play it,” said Anita. My favorite dishes: Straight-Shooter Sally’s sweet potato casserole, Gigolo Giorgio’s jalapeno guacamole, and Persevering Pete’s homemade rolls. Most of us elected to bring wine or beer rather than expose our weak skills in the kitchen, resulting in 10 bottles of wine and 6 six-packs arranged on the serving table. At 9:00 pm on the dot, 20 classmates whip out their phones to play HQ, a streaming, single-elimination trivia app with a live host. None of us get to share in the $5,000 that is divided among contestants who correctly answer all 12 questions. Classmate Butch Brock and his girlfriend Annabelle the Beauty made it to questions 6 and 7. Annabelle recently moved in with Brock, studied communications at a state university, works as a hostess at a local restaurant, and has decided to apply to PA school. Lanky Luke: “Isn’t there anything else people want to do besides medicine?” Jane and I left around 10:30 pm.

This Week in Facebook Activity: Type-A Anita shared Huffington Post’s “Trump Official Blocked Immigrant Teen Rape Victim’s Abortion Because He Personally Opposed It” and added “Tw: rape [Trigger Warning] Hot Take: if you’re a leaky pile of garbage concealed in human skin, you forfeit the ability to tell others what to do with their very real Human Bodies. no one can decide whether or not someone’s reason for an abortion is “good enough”. Anita shifted gears from attacking our weak commitment to advancing non-white causes to attack a non-white political candidate: “Anyone who invokes God as an unquestionable authority in a secular debate on REAL WORLD phenomena has no place in government. This woman, Angie Reed Phukan, is running for Comptroller of Maryland, and decided to let us all know what actual garbage she is ahead of time. (Anita has never lived in Maryland.) Later that evening, she shared an article on Viagra’s patent expiration: “by all means let’s help old dudes keep an erection but keep reducing people’s access to contraceptives #godwantsyoutohavelimpdick” Pinterest Penelope shared that one on Facebook and messaged the class GroupMe: “The hashtag!!”

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane and I join her college girlfriend who works as an au pair and bartender in Dunedin, New Zealand. In order to stay in New Zealand, she is signing up for a master’s degree in international politics at a university there, using $17,000 in U.S. Federal student loans. (Editor: the U.S. welfare program for university bureaucrats now embraces the entire planet! Separately, if so many young people study international relations, why are there still wars?)

More: http://fifthchance.com/MedicalSchool2020

1 Comment

  1. Anonymous

    March 11, 2018 @ 7:44 pm

    1

    In the same mechanic episode, Larry pretends to be on the spectrum and gets his car fixed for free!
    :

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