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Monthly Archive for May, 2006

no reason (season 2, episode 24)

FOREMAN: And why do we care?
HOUSE: Because we’re human beings. That’s what we do.

HOUSE: Where are you going?
FOREMAN: You’re an ass.
HOUSE: I know. Where are you going?

Judging by the oily buildup in your hair, I say you’re lying.

I always say if you’re gonna get shot, do it in a hospital.

I got shot. Diagnostically boring. Big fat tongue on the other hand. Endlessly entertaining.

CAMERON: Lie down. You’ve got to be in pain.
HOUSE: Not today. Today, I’m on morphine.

You can’t because that would involve physically touching me and then things would get so sexually charged.

I’m twice your size. Get your hands off me.

Since getting shot is not an FDA-approved treatment for anything, it means something must have gone wrong in the surgery.

MORIARTY: She lived. You cured her.
HOUSE: I’m truly sorry I did that.

Now I’ve gotta pay because you couldn’t keep your little killer in your pants.

Don’t worry. It’s not insulting, at least not to you.

Sevens marry sevens. Nines marry nines. Fours marry fours. Maybe there’s some wiggle room if there’s enough money or somebody got pregnant, but you’ve got at least three points on your husband and your frock says you didn’t do it for the money and your breasts say that you haven’t had any kids.

I remember. I was there.

If you kept your pistols in your pants—

Here’s how life works. You either get to ask for an apology or you get to shoot people, not both.

If my stitches pop out again, I’ve got three doctors to save me.

WILSON: The guy who sees connections between everything yet sees no connection between being shot and minor brain disruptions.

You messed with my brain.

Don’t worry. I’m sure something else is wrong.

I wouldn’t have hired him if he wasn’t smart.

I can run like the wind but I can’t think. Seeing as how I’m too old to become a professional athlete, it looks to me as if she screwed me over big time.

If I enjoy hating life, I don’t hate life.

Nobody tries to screw up. They just do.

WILSON: Even when you’re out of your mind with anger and fear, you still couch it in logical terms.

People suck. People have turned you from a guy with a swollen tongue into a guy with one eye, one ball, and a stapled-on face. If you want someone to hold you while you cry yourself to sleep at night, choose warm and soft. If you want someone to write you a poem, pick the sensitive loner. If all you care about is that something is done right, pick the guy with the metal head.

Yeah, if only I had dedicated my time to finding

I care because I live. I can’t care if I’m dead.

MORIARTY: I don’t want to hear semantics.
HOUSE: You anti-semantic bastard.

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how to freak a neurotic med student out

Be their PCP and call her (or more accurately, have a PA call her), telling her, “Dr. X would like you to come in to discuss your lab results.”

What’s there to discuss?! It was just my annual exam! There’s nothing to discuss unless there’s actually something wrong! And if there’s something wrong, why can’t you just tell me?! Now I have to wait two whole anxiety-filled days before I even find out what’s wrong giving my crazy med student mind plenty of time to come up with all the worst possible diagnoses. And if it’s not so serious, wouldn’t you just call in a prescription to the pharmacy and have me pick it up? Why do I need to see you? You wouldn’t be wasting precious office time with me if it’s not serious. Which just serves to freak me out all the more.

All freaking out aside, I doubt that my reaction is any different from what non-medically trained patients feel. Hearing your doctor say, “We need to discuss your lab results” is just like hearing your significant other say the dreaded, “We need to talk.” Nothing good can come of it and the anticipation just drives us crazy. Is there a better way of breaking bad news though? Not really. I probably wouldn’t want to hear that I have six months to live over the phone. But being told that I need to come in to hear the news doesn’t make it any easier. It implies that something is wrong because if everything were okay, I wouldn’t have to come in at all. And that sets off a whole frightening world of possibilities that may or may not be ultimately confirmed when I finally do see the doctor. If my fears are confirmed, then will I feel better? Probably not, because I would have preferred to know sooner instead of waiting days to find out. What if my fears are baseless and it’s just a minor issue? Then I’ll wish that I was just told on the phone so that I wouldn’t have freaked out all those days while I was waiting to find out. It’s a no-win situation.

With all of the demands of medical practice, it’s often difficult for us to fully empathize with patients and see how a seemingly harmless action (such as the simple “we need to discuss your lab results” phone call) can have a drastic effect on a patient’s life—how we can put a patient’s life on hold with just a few simple words. Experiencing these things firsthand as a patient helps remind me of what it’s like to be in the patient’s shoes and to more closely pay attention to such things, even if there are no easy answers (a big plus for INTP-me, who has a hard time empathizing with people in the first place).

grand rounds 2.35

This week’s Grand Rounds is now up at Parallel Universes. Enjoy!

why, oh why md/phd?

Now that we’ve gone over what’s involved in this whole MD/PhD thing, I guess it’s time for me to go into why exactly I chose this path.

I first thought about what I wanted to be way back in second grade when we had to include a page on just that in our little “All About Me” books. I said that I wanted to work in a laboratory complete with a drawing of me in a lab coat and glasses with various beakers in front of me.

In high school, I decided I wanted to be an astronomer. Maybe it was because I was already looking to find a planet I could inhabit far, far away from all the annoying sand people a la Le Petit Prince (The Little Prince—a great little book to live by—read it whenever you need to ground yourself a little). Of course, this plan didn’t settle all too well with my parents and I knew that it was also just a tad unrealistic, so I opted for the more run-of-the-mill something-in-the-sciences-I’m-not-yet-sure-what plan when I went off to college.

Becoming a doctor was always in the back of my mind though. But I wasn’t sure that I had it in me. And I didn’t want to do it because my parents wanted it of me. And I was quite interested in something engineering. But in the end, after doing the appropriate pre-med things, I decided that becoming a physician was definitely what I wanted to do.

When I visited my old high school math teacher and told him that I was going to pursue medicine, his reply was, “So we lose another great one to science.” I was good at everything in high school, but I really loved math, especially calculus (seriously, I’m not kidding). So much so that I took the engineering math series in college (though just the last of the series because of AP credit). Then I forgot all about my love of math as I focused on the usual pre-med classes. Then I realized that med schools don’t quite like AP units being used to fulfill requirements (I guess it wasn’t that important since it was math, but I was in crazy-pre-med mode then). And then I put it off because I had already taken the last in the series and was left with moving on to more abstract-engineering-type math. I eventually ended up taking vector analysis, which I thought would totally kick my ass since I’ve never been good at vectors and since it had been so long since my last math class. Funny—I kicked its ass instead. I had one of those crazy-into-math professors who made the stuff so complicated that we were required to go to office hours just to understand how to do the homework. Well, I went to one and got bored to death. So I never went again. And I still owned the class. And I had fun. Which reminded me of how I had turned my back on that whole engineering thing when I chose medicine.

During this whole time, I was also deeply engaged in research, which I also enjoyed immensely. In fact, I was a little sad to leave it behind for medical school. I don’t know why I didn’t consider it before (it probably had something to do with my thinking that I wasn’t competitive enough), but I eventually got into thinking about trying to do an MD/PhD so that I could pursue both of my dreams: medicine and engineering. And that’s how I ended up here. Miserable. But doing what I wanted to do. I guess it’s just the getting there that’s not so fun.

safe (season 2, episode 16)

HOUSE: You answered?
WILSON: Turns out that’s what stops the ringing.

Six months without putting out, Dr. Cuddy doesn’t need to wear thong panties, but it’s not our call.

What sort of exercise could a strapping young man and a nubile teenage nymphet possibly be—

CUDDY: These are your big ideas? Somebody’s lying?
HOUSE: Hasn’t let me down yet.

CAMERON: You had unsafe sex? The whole unsafe thing didn’t tell you something?
DAN: Yeah. But we didn’t like—we didn’t plan on it, you know… just… I don’t know. We’re in love. We’ve been dating for 2 years.
CAMERON: Practically a lifetime. How about a semen allergy?

CAMERON: Too bad it’s not you giving the sample. We’d be done by now.

CAMERON: Love is an emotion certain people experience, similar to happiness. No, maybe I should give a more relatable example.
HOUSE: Oh, snap! What did he do to protect her? Brillo-pad his privates?
CAMERON: I assume he washed and he—
HOUSE: Oh good work! Assumptions are so much faster than actual questions.

Don’t worry. I’ll return him in roughly the same condition.

This is the one downside of teenage sex. You’re idiots.

Think lower and more fun.

Great part of being a grown-up: you never have to do anything.

New puzzle piece, always good news. What’s the bad news?

I need a lot of foreplay. And then there’s the cuddling afterwards.

Have you seen the centerfold? There’s no way those valves are real!

HOUSE: Lying’s more fun.
WILSON: Being lied to, not as much fun.

Foreman’s right, we’ve got to find out why she’s paralyzed. But not before staring at me dumbly for a few seconds.

Only way to confirm this is to inject a rat with her blood and wait for it to go all botulistic on your ass.

In the meantime, I’m going downstairs to browbeat a scared dying teenage girl until she breaks down into a scared dying teenage girl.

Lying to your parents is usually the right thing to do but there is an impending death exception.

Well, that wasn’t nearly as dramatic as I’d hoped, which just means the next time will be even better.

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all in (season 2, episode 17)

We’re smaller and better than chimps, bigger and worse than gorillas. For all our rationality, our supposed trust and fealty to a higher power, our ability to create a system of rules and laws, our baser drives are more powerful than any of that. We want to control our emotions, but we can’t. If we’re happy, things don’t annoy us. If on the other hand, we’re sitting on crappy hold cards, little tiny things annoy us a whole lot more.

HOUSE: Hey! How’s that anal fissure? Did it heal yet or is it still draining? Oh, I’m sorry, didn’t realize you’d come back for seconds. I figured that after the girl on the stairwell you’d be done for the night.
CHASE: He’s joking.
HOUSE: No Adam’s apple, small hands. No surprises this time.

Geez. You get testy when you don’t get any fuzz.

Subordinates can disagree with me all they want. It’s healthy. People who can shut me down on the other hand—forget Cuddy, I’ll have Wilson keep her busy.

COFFEE MACHINE: Good Coffee, Cheaper than prozac!

It’s new. New is good. Because old ended in death.

Either you go all in or I’ll tell everyone in the building that you wear toenail polish.

These procedures would be much simpler if you could do them on healthy people.

HOUSE: So Foreman, you agree with both of them? Thanks for playing.
FOREMAN: If we have enough tissue for two tests, why not do both?
HOUSE: Then we wouldn’t have to think as hard. Taking the pressure off the choices makes us less likely to think critically.

You know, relative to its size, the barnacle has the largest penis of any animal.

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so how exactly does this md/phd thing work?

Perhaps this whole MD/PhD thing deserves some explanation. Or perhaps I just don’t really have anything else to write about and am using this topic as a filler post. You be the judge.

Let’s not go into why I chose to torture myself so just yet. Let’s just focus on what’s involved in this torture.

The Medical Scientist Training Program (MSTP) was established in 1964 by the National Institute of General Medical Sciences (NIGMS) to address the need for investigators who are well trained in both basic science and clinical research. According to the NIGMS, there are 40 participating programs and 75 medical schools that offer combined MD/PhD degrees without funding from the NIGMS.

So what exactly is involved? At my school, the combined degrees are expected to take seven years to complete. We start out in medical school, finishing the first two years of medical school (the basic science part) and passing our USMLE Step 1 before leaving medical school to start our graduate work in our area of interest. During the first summer of medical school (which is the closest that we get to the summer vacations we’ve been used to), we don’t get to kick back and relax or travel to exotic places or even catch our breath. Instead, we are required to rotate through a number of labs in our area of interest to try to find the lab that we want to do our thesis work in. As I mentioned earlier, instead of going on to the wards during our third year of the program, we start our grad school work. Depending on the field we are going into, graduate courses need to be taken to fulfill the PhD degree requirements. A field closely related to medicine, such as physiology, will have a lot of overlap with the medical school curriculum, leading to fewer courses needing to be taken (or so they claim). In contrast, a field such as biomedical engineering, which isn’t so related to medicine, requires more coursework to be taken. Simultaneously with the coursework, we are expected to be working in the lab (either rotating through labs if we haven’t yet chosen one or in our chosen lab). Graduate programs tend to be a little more flexible with MD/PhD students as well—how this so-called flexibility manifests really depends on the specific graduate program. After completing our required graduate coursework, we must go through the torture that is the qualifying exam just as in a PhD-only program. Then we are free to complete our research, all of which should take a mere three years. Once we’ve completed our thesis work to the satisfaction of the powers-that-be, we’re released back into medical school, where we complete our last two years of medical school. There is supposedly some flexibility in the curriculum for us during the last two years of med school as well, since we usually don’t start right on time to begin “third” year with the rest of our MD-only classmates—however, I’ve heard that they’re becoming less and less flexible (which means I’ll really be screwed by the time I return).

And that brings the grand total to seven years, if we’re lucky. If we don’t complete our thesis work in three years, we just keep going until we do (but the funding just might not, depending on the school and the program).

So where am I in this whole grand scheme? I’m just going over the hump that is the middle. I have one year left before going back to med school IF I stop conveniently sabotaging my own experiments. It wouldn’t be so bad if I knew for a fact that all I have left is this one year. But I don’t. So it’s just sheer torture.

how to really quickly irreversibly ruin your experiment

It’s quite simple really. All you have to do is inject 3 cc of air directly into the right atrium of your unsuspecting experimental animal. Yep. It’s as simple as that. And how to do that short of wielding an air-filled syringe and stabbing it directly into the sweet spot?

The handy-dandy device pictured here is a stopcock. It’s used as a valve to allow one catheter to be connected to more than one thing. We use many stopcocks in my study—on the arterial line to allow connection to the blood-pressure-heart-rate-machine-thing with an extra port for blood draws, on the venous line to allow connection to the central-venous-pressure-machine-thing with an extra port for infusion of valium for sedation, and another stopcock on the same venous line to allow saline injection for measurement of cardiac output with the other port used for blood draws. And that’s not even the half of them apparently.

We measure cardiac output using the thermodilution method in which cold saline is injected into the right atrium and the change in temperature measured. I’ve run this measurement many times before in all of my previous failed (for other reasons) experiments. I always double and triple check all of the stopcocks before injecting saline. And I did no different today before starting my measurements.

Here’s what I was thinking as I was taking my readings:
Okay. First reading: 1322 ml/min. That’s a little high (but in the realm of normal for this animal). Let’s run another one…
Uh. Why is there only a flat line tracing (as opposed to the usual curve) and no reading? Well, not to fear. This has also happened before (or maybe not…what I meant was that the cardiac output machine has done funky things before). Let’s just run it again.
Still a flat line.
Hmm…why is the respiratory-machine-thing alarming? Well, that also happens a lot because this animal likes to breathe against the ventilator and the normals are set at human values.
Let’s just hit that “silence alarm” button.
Hmm…why does it say “apnea (which means that breathing has stopped)?” That’s a little odd. But that’s also happened before—when someone stepped on the line connecting the animal to the respiratory-machine-thing. [looks to see if someone is stepping on line] No one’s stepping on the line.
Crap. Are my lack of cardiac output reading and this apnea related? The apnea did seem to start right after that second attempt at a cardiac output reading. Can’t be, because that means I did something wrong and I triple checked all the stopcocks and I flushed out the saline injection line before using it…

At this point, Collaborator-doctor-man finally notices that there just might be a real problem (the alarms go off a lot in our experiments—we’ve become quite adept at hitting that “silence alarm” button). He glances over at the cardiac output machine setup and notices the problem: the stopcock attached to the very end of the saline bag was in the closed position. Which means that no saline was being drawn into the injector-thing. Which means that the injector-thing was injecting AIR instead of saline into the animal when I tried to take my cardiac output readings. Which means I gave the animal an air embolus that probably went straight to its lungs. Which was why it was apneic. Which means that I so just ruined my entire experiment by killing the animal.

The irony. We’re always so careful to flush out every single line with plenty of saline and to check our syringes twice to avoid little tiny air bubbles because the animal we work with is quite sensitive to air emboli. And here I am, injecting not a little tiny bubble or even two, but 3 whole cc of air into the poor animal. All because some weirdo decided to put a stopcock at the end of that saline bag. Who would do such a thing anyway? Leaving it in the closed position no less? It’s almost as if my major professor snuck in when our backs were turned and sabotaged me just so that he can torture me a little longer. I wouldn’t put it past him. Well, I learned my lesson here. Stopcocks are not my friends.