lub-dub

Last Thursday, on the last day of this year's first month, thirty and some of us sat in a lecture hall with stethophones on our laps and in our ears, listening to heart sounds that a stout doctor committed to principles of the physical exam played for us on a mysterious machine that used infrared waves to contact some rectangular box attached to our devices. His words are clear and serious. You've all been listening to normal hearts. It's important to know what abnormalities sound like. Know murmurs. Here's what mitral regurgitation sounds like. Once you hear it, you'll never forget it. First I'll start out with the normal heartbeat, and then I'll add the murmur.

We listen and wait. Here it comes. Lub-dub. Lub-dub. So soothing and constant and rhythmic and after such a long day, more than a bit sleep-inducing. I see him turn a knob and then whooosh. There's the murmur. Lub-d--whooosh--ub. Lub-d-whooosh-ub. I thought, suddenly--wow. That's it. My life is this lub-dub and I'm that whooosh that's just passing it by.

*

Thursday began with a 9 AM lecture on renal physiology. In college I hated studying the kidney because there are so many parts and each one functions intricately differently. But it's true that repetition helps, because after a very cursory look in college, the first overview lecture here, and the histology lab, I wasn't as intimidated by having to hear someone talk about how the kidney reabsorbs salt and water for an hour. It turned out to be an hour lecture on the proximal tubule (1/6 of the kidney's tubules). Just the proximal tubule. It was surprisingly good. The proximal tubule is a hard worker and very smart.

From 10 AM-1 PM we had our last anatomy lab. It was the most brutal we've had, and yet anticlimatic. I haven't been too bothered by the physicality of anatomy; it's been more beautiful than disturbing. Removing the chest wall, dislocating the shoulder, uncovering the hand muscle by muscle--it's all been for something, even at times we spend more time with dissection than actual visualization. It never seemed disrespectful, and we are reminded so often of what our donor should mean to us, to respect their gift.

This time, the sounds and movements and my own inability to distinguish anything in the nasal and oral pharynxes made the procedure seem unnecessary and made me feel sorry for doing it. It involved sawing the head--skull and all--in half. Through the nasal septum, if you managed to be exact. The sound was in one word, awful. We used a manual saw, and it was worse than the loud grinding of the mechanical one we've had in the past. Because the exertion was so obvious and physical, the back-and-forth and the amount of time was palpable.

Perhaps I should have prepared more, but the fact that I didn't know anything about the nose and mouth and gained very little from the lab made me feel infinitely more guilty for doing this to our donor. I don't attach too much significance to the body after death; I'd like to be cremated and I have some sense of some sort of soul. So it's not like I prioritize bodily preservation, but the sacred the body holds when alive can't help but remain.

I will remember where I saw my donor's ligamentum arteriosum because it made sense based on what I knew about it--I remember Rizzolo forcing us to reason out why it would be there and how satisfying it was to confirm it both anatomically and intellectually. I will remember the long tendons of his arm and hand and moving them to move his fingers, my favorite lab. I will remember the subdural hematoma that engulfed his brain and how that both fascinated and hurt me. But how much anatomy will I remember? Likely little. Are those memories enough to justify everything else? I'm not sure. I'm not sure if it would be enough for me to give myself up, even as a person who thinks little of what will happen to my body after this is all over.

And so, it ended. Not quite with a whimper, but definitely no bang. Allison and I were talking afterwards about whether we'd have strong visual memories of our donors. I said I didn't think so, because we never looked at the body in its entirety. We always covered parts we weren't working on, including the face, which would be easiest to remember. It's hard to really retain vivid images of things in isolation.

Yet--though I don't feel I've solidified an image of his body or even his face, I do know I've acquired, in slow and fast gulps, an entirely new perspective of body. They say anatomy is a rite of passage, and it is. It is, not for all the arteries and nerves and muscles, but for the new and complex and strange and wordless.

After lunch (and no, it's not really strange at all to eat after anatomy lab), I made a quick run to the post-office to drop off my ballot for Super Tuesday; the fresh air was nice. Then I had a meeting from 2-2:30 PM with a professor at the Public Health school. It was one of two required meetings for my application to go to Vietnam this summer. I'm hoping to do a social health project to evaluate the effects of the healthcare system on low-income patients, in terms of their living conditions, employment and education. The professor was helpful in telling me what I needed to do to make the study design tighter--which is the most difficult part of the whole thing. If it pans out, I'd be based in Hanoi, but also live with a family in a rural commune while doing fieldwork. Talking about the finer details made some anxiety about getting it all done re-surge, but I'm hoping very hard it works out.

From 3-5 PM we had Pre-Clinical Clerkship. Since the new semester started, it's been all physical exam. I honestly hadn't given much thought to doing the physical exam prior to this; despite it being a core experience, it wasn't something I associated with medical school like I did with anatomy. I guess I couldn't really see myself doing it. It's been fairly incredible. I feel as inept as ever, but small improvements like actually knowing the names of my instruments and how to hold them makes me feel disproportionately good. The fulfillment of DOING stuff gets so lost in academics, and it's been refreshing to feel things very concretely.

The hardest thing thus far has been using the opthalmoscope to look into people's eyes. You have to get uncomfortably close to a person's face to do so, and keep one eye closed. I discovered what a struggle it is to keep my left eye open when my right's closed. Then seeing the person's blood vessels is surprisingly difficult--finding the optic disc near-impossible. After many, many tries on different weeks I finally saw one, and again the excitement was too large for such a tiny thing.

Dean Angoff introduced our introduction to the physical exam by saying how important it is to feel the discomfort, anxiety, vulnerability of the patient. That by being patients for our partners to practice on, we have some sense of what it's like to have to bare yourself for inspection. I love Dean Angoff, and I love that after so many years in medicine she is still so in tune with people. I have definitely felt anxiety being the patient, and she makes me remember to be thankful to have that feeling to draw upon in the future. I'm not going to lie. Taking my shirt off for the lung and heart exams was uncomfortable. Actually, even having a light shone in my nostrils was discomfiting. And that's with an awesome partner who couldn't be more considerate. I imagine it's worse for a patient, who doesn't even know why we're doing things, whereas we understand why someone's poking us in this place and that.

The physical exam has also added yet another thing to draw our class into a cult, of people who torture each other with bright lights in our eyes and amateur percussing and hesitantly sticking otoscopes in our ears without damaging something in there. I try to step back and look at that from the outside, and it amuses me and find that as awkward as it can be to do this on people you know, it's another aspect of the med student bond. However, I welcome any of you to be my patients for practice.

This week's physical exam practice was supplemented with the heart sounds session I mentioned before. It is amazing to hear something buried in you beating in your ears. It is extremely hard for me to distinguish sounds, which beat is louder at certain places, the timing of a beat and an underlying/overlying murmur. It's such an art.

The day finally officially ended, and I spent my hour before dinner ordering books--Let's Go for PUERTO RICO, and yet more Murakami to read while in PUERTO RICO. After a five-hour planning party wherein ten or so people were in and out of my room on three computers searching for travel deals and spilling tea and yogurt on my sheets, we booked TWO rooms for FOURTEEN people in San Juan. Six nights, six-and-a-half days with packed, co-ed rooms. I am so excited, and so glad that all my good friends here will be together in another country with no med school frenzy.

After a nice dinner (our dorm food is always bad, but company is always good), I thought about doing work, but ended up g-chatting with Allison for a couple hours about boys, school, motivation, friends. Even though we're so busy, I think we all give a lot of thought to our experience here--why and how. It's necessary to stop to consider what we're doing, because it's so easy to get swept up in the rhythm of things.

I did manage to review the kidney lecture from the morning, but that was about it before we headed to PubMed. PubMed is a free party with open-bar on the first floor of our dorm. Its convenience cannot be beat. We got pretty tipsy. Some of our classmates who have formed a band performed several songs. Events like this make me want to grow super arms to hug my entire class at once. They are so goofy and amusing and supportive of one another. I like how, since the first day we went out, we can all dance with each other in complete innocence and fun. He and I had a tiff and a moment, which consumed most of the night but ended with me glad for how people surprise you.

*

I don't write much about daily happenings, because for me they don't give a good impression of how things are. But giving a sense of what medical school is like is difficult. Thoughts and responses clamor for space and it's hard to fully revisit any one of them. Thursday, January 31 was a long day with a smattering of almost every thing that comprises my life here, and one I'd like to remember in detail. I'd like to calm that murmur and listen to the beat of things.