Aditi likes yellow flowers.
and pink ones too
daffodils

flying elephants

Video from You Tube.

Everyone has their moments where you do something stupid in a spontaneous instant of thoughtlessness and realize immediately afterwards that it was a mistake. Ideally these events are swept under the rug, never to be thought of again; however in reality embarrassing moments tend to be resurrected when you least expect it. Take a lecture of the neuroanatomy of the midbrain for instance. Our brains are amazingly adapted to process the information from our environment and focusing on that which is important. Undoubtedly, circumstances in our environment change and what was once environmental noise becomes acutely salient. Imagine walking down a sidewalk chatting on a cell phone. You don't consciously think about moving one foot in front of the other, nor do you have to visually focus on the stop signs, mailboxes, trees, fire hydrants, and other features you pass. You're aware of them but they don't command attention. In this mental zone, you cross an intersection and suddenly your brain surges and you notice the semi truck charging towards you-immediately stealing your attention and causing you to speed out of harms way. The superior colliculi in the midbrain tectum is responsible for directing this visual attention (FYI the inferior colliculi are involved in auditory processes). To beat a dead horse, this is also the area often involved in the startle response in horror movies ---the dark, eerie mood music before something or someone jumps from off screen and says boo (or worse)!

I first learned about the colliculi six years ago when I was enrolled in Introduction to Cognitive Neuroscience course as a freshman at DU. During midterms, I was having a study group in my room in J-Mac with a neighbor also enrolled in the course while my roommate was on his bed, studying for a computer science test. In a moment of inspiration when we made it to the superior colliculi on the review guide, I picked up my stuffed elephant and chucked it unannounced at my roommate, intentionally aiming to miss his body and enter his peripheral vision to "demonstrate" the function of the superior colliculus. Unfortunately I miss judged my own strength and aim indeed missing Kevin's body instead making contact on his laptop sitting on the desk which proceeded to slide off the edge onto the floor with a loud crash. The unintended consequence of knocking off his laptop with my stuffed elephant did indeed direct the attention of everyone in the room in disbelief both at me and at the humpty dumpty laptop now on the floor. Flushed red I offered my sincerest apology stuttering something like, "i'm so sorry, I was just trying to test your superior colliculi response, I didn't mean to hit your computer, I was just aiming at you..."

Fortunately, my computer science roommate was able to repair his computer without lasting deficits and he even accepted my explanation for the vicious elephant-computer assault. Furthermore I passed my cognitive neuroscience midterm blocking out most recollection of the study session completely. That was of course until last week when I was in a group study session cramming for the Neuroscience Systems exam tracing tracts from the spinal cord through the hind and midbrain sections. Although we were focusing on the anatomical/histological regions of the sections, rather than the functional, I turned to my study partner and said, "you know, the superior colliculi is involved in the startle response...we should test it out!" A little voice in my mind started screaming-NO DON'T DO THAT!!! Do you remember the last time you tired that???


Image from Dr. Bales- G. Bales / Medical Neuroanatomy / Brainstem Topography 3/10/08

Lions in the classroom

I’m not one for horoscopes but this month can’t be high for love and medicine. Within a week three of my neighbors in close relationships have broken up with their significant other; including me. As some of these friendships ended mutually others ugly I am abruptly reminded about the advice given to us during orientation week by a firecracker clinician, “make an investment in your tools (stethoscope, ophthalmoscope, otoscope, and sphygmomanometer) I’ve kept mine longer than my wife.” I refuse to believe that in a career focused around people in need, it is impossible to support the needs of those closest to us, our friends and family. We first need to make an investment in each other to give purpose and meaning to anything else we value…everything else is relative.

Equally interesting is the observation of how we react to the emotional stress of ending or changing relationships with those we value--by running into retreat mode. For me it’s been hyper focusing on school extracurricular---Montclair clinic, Trends in Autism conference, and cramming for Neuro – anything but emotions and the future, only immediate survival. For others it has been an escape home away from the “drama” of campus, and for the third, it has been to hide literally, from his soon to be ex in order to study. I am sitting here learning about the catecholamine drugs--- Fight or flight response –and the impact these neurotransmitters have throughout the body. It is hard to believe that it is as simple as neurotransmitter soup that has made the last few days (and coming weekend) such a challenge. One amazing attribute is the brains ability to override its most basic reflexes— including pain. One of the first tenets we learn in Neuroscience is that pain is a perception of nociception from the pain receptors of the body. You can have the nociceptive response without the pain – we’ve all heard horrific accounts from war heroes who continue without pain-despite mortal wounds, or tales of professional athletes who perform despite broken or sprained extremities. The alternative process—pain without nociception is all too common—chronic pain which can be equally debilitating. In light of that…neglecting emotional distress is probably as pathologic as chronic pain but today feels as necessary as retreating from the heat of battle despite injury that might otherwise redirect all attention.

Homeostasis—the process of being in balance is controlled by parasympathetic’s predominance in the balance of life. This “feed and breed” pathway sets the tone while the "fight or flight" provides reserves when we are threatened and need to escape. It’s amazing that we have a system that can persist by the very fact of forcing you out of balance. It’s equally amazing how any alteration in our proverbial “feeding and breeding” desires automatically throws us into the turmoil of fight or flight, as if we were being attached by a lion, despite the fact it involves those we love.

This semester has emphasized two very important facts --- Exams are NOT LIONS that require a full blown sympathetic response; neither are friends, girlfriends, and family. As med school consumes my life in the process of molding me into a future physician I need to discover ways to remain in homeostasis with my body and my surroundings –not in attack mode. Until then, I hope the adrenaline lasts until spring break when I hope to experience true catharsis.


"...because you can't fight a bear when you're urinating[from the caption]."
Image from Dr. Wong's Introduction to Autonomic Pharmacology lecture 3/10/08.

getting shit together

It is always fun to have visiting professors and clinicians give lectures. It helps to emphasize what other experts feel is most important, provides a measure of reassurance that what we are learning is consistent with our peers at Loma Linda, USC, UCLA, or UC-Irvine, and it forces students to be on their best behavior. Not to be overlooked, visiting professors provides another venue for bad jokes and sage sayings.

How do you hide a $100 bill from an internist?...put it under a dressing
How do you hide a $100 bill from a surgeon?---put it in a book
How do you hide a $100 bill from a plastic surgeon***You Can't!

To supplement our Blood and Lymphatic system we have had a visiting Harvard trained hematologist currently working at UCI med school present us the essentials of leukemias, lymphomas, and anemias. As the topics in our courses get more multifaceted and complex, ultimately there is a tedious amount of details to memorize. Clinicians who have "been in your shoes" and have years ago completed med school inevitably give a motivational introduction or conclusion to their topic. Each message has its own flavor but they all have a common trend-- it will all make sense in residency! As we approach our next exam weekend Doctor Howard conceded that there will be a lot to memorize. To put memorization into context he explained his most memorable med school moment to us before starting the 9th lecture hour of the day. Following a particularly difficult block at school he and his roommate decided it would be a good idea to host a party inviting all 160 students from his class and the 160 students from the second year class. His most enduring memory is of his downstairs neighbor coming up to complain that the plaster was falling off of the ceiling followed shortly thereafter by the police to break up the party. Having narrowly escaped legal disaster he successfully finished Harvard and moved on to bigger and better things- putting us through the memorization gauntlet. This musing is my attempt to keep things in perspective; what we remember is a heterogeneous mixture of facts we cram to memorize, random trivia that we never can forget, complex algorithms we use daily, and snapshots of the people, places, stories, and events that make life joyful and memorable. Despite my headache organizing drugs, symptoms, side effects, disorders, and the hours in a day, I cherish the ability to memorize and have memories.

Dr. Howard's parting words were the heirloom wisdom that he received during his first year of rotations from a chief resident: All you need to do to survive life as a medical student and later on as a physician is to remember the 4 laws of shit:
-know your shit
-do your shit
-give a shit
and don't take no shit

...Now I'm off to memorize this shit.

Picking apples, Bongos, and spotting

It is amazing how short 24 hours seems and how long 18+ hour days feel. Finally I've made it to the medical school people imagine--long nights, early mornings, lectures, libraries, mnemonics, microbes, drugs, and no time. Nonetheless, while the length of a day remains constant, I am still discover new ways to fit/replace/combine more activities into a day simultaneously juggling with what to excise. Fortunately it has not been a bitter pill to swallow as it is possible to find at least something pleasant in arduous work--studying all day at Panera Bread Company, reading flashcards at the gym, experimenting with new teas between study breaks. I have inevitably had to make some sacrifices to remain only moderately insane. I've started to occasionally exercise at the gym rather than going on hike: an inverse from my pre-med days; I'm eating Trader Joes frozen meals or frozen leftovers scavenged from the parents, or food of unknown origin left in the student commons rather than cooking or eating out; I've practically given up TVs, movies, this blog, free reading.... I have still appreciated life as it goes by in part because I have to mentally justify every distractor I indulge ensuring those activities that steal my time from studying are either required for sustenance (eating sleeping), civility (laundry, hygiene), academics (class, professional requirements), and most importantly sanity--because they represent who I am at the core. Some activities I could not give up regardless of other time constraints- I still have my grandpa's keyboard--always turned on, just in case I have time to run through one song between chores and school. I'm constantly connected to Google news or wikipedia. Currently, my chocolate cupboard is better stocked than my refrigerator. It is with this pseudo-rationalization my newest competitions for cram time is picking apples, slamming the bongos, and dizzily practicing spotting.

Adding to the chaotic schedule of February and March, affectionately known by faculty and OMSI students alike as hell month, is Bhangra and Hindi Film dance. My ever growing quest to better understand my culture and heritage has uniquely blended with my path to become a physician. I am now an active member of WesternU's SASA club or South Asian Student Association. I am spending a considerable amount of time dancing--in preparation for the International Medicine club's cultural day March 8th. Each movement has been creatively names as "The King" or "bird man" "puppet" "apple picking" "sexy squats" etcetera. Music and dance have always been a gateway into cultural appreciation. As much as I'm learning about the science of medicine, medicine as an art is interwoven in culture, yours and your patients so I am happy to replace study time with dance. I hope that even through my brain is saturated with pharmacology, microbiology, and pathology, I can organize Apples, Bongos, Birds, puppets, and the other steps associated with dance Bhangra dancing.





illustrations from Weili Zhang.

CH2O

Water (H2O) and carbon (C) are the most basic components of life, the essence of something organic. However when combined together in a simple aldehyde (H2C=O) what remains is the curse of all first year medical students - formaldehyde. I have had to spend all summer surrounded by this substance as I completed an intensive anatomy course and now, one month into the official academic year, I am interacting almost daily with formaldehyde as a facilitate and tutor for gross anatomy. While I've been reassure formaldehyde is only mildly toxic (comparable to EtOH) when inhaled in low doses (as in a well ventilated anatomy lab) the symptoms of formaldehyde exposure are not nearly as pleasant as those following a glass of vino tinto - headaches, irritate eyes, a pungent-lingering odor, and cold or numb fingers. (Aldehydes evaporate quickly taking away body heat). Adjusting to the world of medicine is a process I would guess is not unlike beginning a long sailing voyage - you have to develop sea legs before achieving a sense of confidence and surefootedness. Surrounded by a foreign environment one must quickly immerse oneself in the vernacular and learn the ropes all the while feeling one's worst due to the effects of seasickness. For me formaldehyde brings out the worst. While I'm not over the bow returning my breakfast, I notice myself becoming more irritable and tense after a day in the lab; most likely due to the unpleasant smells, sense of cold and onset of mild headaches. This feeling is juxtaposed by the sense of awe at the human body and the sense of pride being surrounded by a group of peers whom are intelligent, hardworking, and passionate about making a difference in the world. While it is unlikely I can change how my body reacts to the affects of formaldehyde or more broadly, the stresses of adapting to a new environment, I am learning how to navigate through these stressors and take time to decompress and reenergize while still sailing onwards. I hope as time goes by I get better at it and develop my medical "sea legs". Until then, at least I know we're all in the same boat.

Good Grief

Ecclesiastes 1:18- For in much wisdom there is much sorrow, and he who stores up knowledge stores up grief.

During high school in preparation for the AP English exam we had a prompt to support or refute the verse from Ecclesiastes above. As a timed essay, it was a test of critical thinking skills and persuasive writing. I remember refuting the premise of this claim arguing that knowledge is power and the potential good outweighed any potential grief. Now nearly six years later, and 2/3rds into a human gross anatomy course I have been reminded of this verse and am tempted to modify my previous analysis! Indeed my limited pre-medical school understanding of anatomy was more than sufficient for the past 23 years although I was (blissfully?) unaware of the extent of my ignorance. After a few particularly long and grueling days in the laboratory I am now beginning to appreciate the nuances of the lower extremities but instead of mitigating my stress level, it is increasing due to the realization of how much I still don't know and the impending test in a week. A significant component of medical school anatomy is clinical correlations. While I generally appreciate the change in context of gross anatomy from erudite Latin to practical application, two unintended consequences become evident with this approach. First, our better understanding of anatomy comes at the expense of someone else's suffering and injuries; second, limited knowledge if fodder for hypochondria. Two weeks ago, hitting your funny bone on the table was painful but benign- at the risk of sounding insensitive, it could even be considered funny- if it happens to someone else. Now with the simple understanding that it is crushing the ulnar nerve against a table and the medial epicondyle and when done with enough force could cause serious nerve damage and motor deficits- it removes any element of humor. How then does gross anatomy fit into the context of Ecclesiastes?

The answer I believe lies in the insightful wisdom of Charles Schulz and the illustrations of Charlie Brown. Whenever Charlie becomes frustrated he exclaims "Good Grief!" While some may argue that this juxtaposition is an oxymoron, I would offer that at least in academic pursuits grief can be good. As Charlie navigates the world of friendships and school (waah wah wah, wah wah wah waah) he learns life lessons and gains wisdom and knowledge (the good) through his personal trials and tribulations (the grief). One without the other would be incomplete. A medical career is defined by critical thinking, persuasive communication, and good grief. Knowledge and sorrow parallel mystery and joy- that is the true sign that the doctor is in.



Image from http://candygourlay.com/blog/images/peanuts.gif

Note: the waah wah wah sounds produced in Peanut animations is the product of a muted trumpet.
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