12 Things I’ve Learned On Pediatric Radiology

1.  Stupid Thymus Ruins Everything. At least, it ruins everything that I already knew about adult x-rays – which was already largely limited to “where’s the air”, “can I use the word ‘hazy’ to describe this”, and “no evidence of cardiomegaly”

But NOT WITH KIDS. With kids, I’ve learned the correct answer to even simple stuff like “is that cardiomegaly?” is No. No, it’s not. It’s probably just a dumb thymus.  (Except for the cases where it totally IS cardiomegaly, in which case it will look exactly the same.)

Goddamn it, thymus, MOVE. You are in a highly inconvenient location.

2.  When In Doubt, The Answer is “Moderate”. Lymphadenopathy in the pelvis? Sure, I see it – it’s ‘moderate’. Quality of the fibrosis in the portal tract? Moderate. Suspiciousness of that periosteal lesion? MODERATE.

(I mean, not really-  if they’re bothering to ask you, that means the most correct answer is either “very subtle” or “OH MY GOD” – but better to err on the side of “lacks experience” than “is not able to discern basic anatomical structures”.)

3.  Radiologists are geniuses. Every time I start feeling confident about my pattern recognition or image-reading skills (“I could totally sit in a cushy chair and read images all day! This is the best!”), I end up in one of their oral boards review sessions watching them all get grilled on isotopes, ochem diagrams, and physics.

I bet I would’ve loved radiology if I were born 50 years ago when everything was just plain films. Or if I had gone to medical school straight out of high school, before taking so many college pre-reqs.  But I didn’t, so now I’m old and cynical and my general attitude about studying “converging collimeters” in radionucleide scans is stuck somewhere between “THOSE WORDS AREN’T REAL” and “YOU CAN’T MAKE ME.”

4.  Sitting in the dark all day is dangerously relaxing.  My Red Bull consumption is nearing an all-time high, which is sort of disconcerting, since this rotation is basically 5 hours a day, 5 days a week. (I’ve lost my edge! I’ve gone soft.)

5.  Reading a radiograph: The “helpfully point out structures” approach that worked so damned well with the attendings last year does not, somehow, impress the radiologists. (“And what do you think of the vasculature?” “Well, that right there is the IVC. And, uh… it is.. not enlarged. So… it is looking good. … or possibly not good? … Hey, look – it’s patent!”)

6-12.  Fact dump: The newborn liver should always be less lucent than the heart – free air would make it brighter. Ovarian torsion is super difficult to rule in or out with imaging alone. Current wisdom is that “shaken” baby syndrome actually involves impact. The bone equivalent of “hazy” (in the lungs) is “broad transitional zone” and it signifies diffuse disease characteristic of malignancy.

Bone ages are fun to determine, but many radiologists believe the “11 year old” and “12 year old” male standards should be switched, the standard deviations are broad and not, in fact, actually standardized, and it’s all based on cohort data from like 50 years ago.

If the neonate’s ossification centers are visible, it was likely a full-term child, because those come in at 42 +/- 2 weeks. Germinal matrix hemorrhage is echogenicity seen anterior to the caudothalamic groove on ultrasound, as opposed to the echogenic choroid plexus posteriorly.

… best rotation ever.

5 Things I’ve Learned On Primary Care

Actually, I’ve already done primary care. There’s a complicated explanation behind why this extra month exists in Metropolis-world, but to simplify it for blogging:

You know how all of Daylight Savings Time’s well-thought-out reasons for existing were ultimately overshadowed by the awkwardness of creating an extra hour?

Well, picture that, but with an extra month.

Personally, I don’t mind. Primary care is fun, and doing an extra few weeks just means I don’t have to study. It’s the perfect post-Step 1 / first 4th year rotation.

Sure is a tough life. Somehow, I’m powering through the burn.

1.  When our med school lecturers joked that “50% of what we teach you today will turn out to be wrong”, I should not have laughed. I always assumed that aphorism was meant more  ”over the course of a career” than “over the course itself” – which makes the joke less “funny” and more “immediately alarming”.

(Seriously, forget about niacin for cardiovascular end-point improvement, statins for primary prevention in women, and beta blockers for isolated hypertension in anyone. Lies, damned lies, and statistics.)

2. Insurance companies DO care – about electrolytes. The health of my patients has truly never been as prioritized and cared about as it is during the 10 minutes immediately after attempting to order a calcium level.

Yes, THANK THE DEAR LORD you insurance companies have risen up to protect us against the abominable scourge of lab-draws for patients with generalized bone pain; thus forcing us to go straight to the much more fiscally-responsible full-body bone scan.

WELL DONE, YOU. Slow claps all around.

(Yes, I did read the Time article. And all the immediately preceding identical articles that, for whatever reason, never blew up the same way despite containing the exact same information. Seriously, healthcare spending has been a mess for far longer than Time Magazine has been in existence, and while the attempts at fixing it have changed, the underlying reasons have 1) not, and 2) never really centered on ionized calcium, to the best of my knowledge.)

3. How to present a healthy patient, with no complaints, with an unremarkable annual physical.

“So… in conclusion, my plan is to shake their hand and wish them a good year.”

4.  Career-wise, I am a cheap date.  My preceptor gave me my own office for the month. It has a phone line! And a desk! And a window!

And that was the moment I knew I was going into primary care.

(I’m kidding. Still, it’s amazing the difference a desk can make: call me power mad, but the last time I had my own office I was 8, and it was a re-purposed Fisher-Price box.)

5. Fine, Geriatrics really DOES deserve to be a specialty. I’ll admit it – I was never convinced the Science of Old People ran much deeper than “\dose adjustment” and “avoid the hell out of anticholinergics”.

“This specialty’s inability to take itself seriously is reflected in its inability to find a title that it’s comfortable with. ‘Geriatrics’ was discarded because many practitioners resented being a ‘geriatric consultant’. ‘Gerontology’ was toyed with, as it made their discipline sound much more scientific. However, this was dismissed as inappropriate for exactly that reason.”

- John Larkin, Cynical Acumen

But I’ll give this to them: pain control in the elderly is a nightmare.  NSAIDs are right off the table, opiates and trazodone are great recipes for broken hips and delirium, gabapentin isn’t exactly the drug of choice for arthritic pain, and it’s hard to muster up the untempered enthusiasm to encourage daily acetaminophen use.

USMLE Step 1: The End

It was hard.

I mean, I knew that already – but I wasn’t 100% sure until I became formally acquainted with the “5-minute warning” pop-up.  (Oh, we spent some quality time together that day, “5-minute warning” and I.)

But the time pressure felt bizarrely reassuring, because I knew – having gathered some solid evidence from taking all 7 NBMEs in the preceding 7 days – the easier I find a test, the more patently obvious it is I’m missing something.

(And by “something”, I mean, “roughly twenty questions more than usual”. Dumb, sleep-deprived, face-palming mistakes on the order of repeatedly trying to swipe your driver’s license at the check-out till).

In fact, the only two practice NBMEs I was just SURE I had nailed were, ultimately, my two lowest scores (by a downright embarrassing margin). And the only two that had me reduced to tears, seconds away from dialing the Office of Student Affairs to sound the Official “Help, I’m A Risk to Our Pass Rate” Alarm? Those two scores were twenty points higher than the rest.

So, right – test was clearly hard, so I felt good. I went back to my hotel room, wikipedia’ed all the questions I was unsure about (common sense be damned, I was curious as hell), marathon-ed half a season of House of Cards, and moved on.

But now its one week later, and while I haven’t thought much about the test, I no longer feel “fantastic” about it: After a week of feeling cheerful, my mental pendulum has slowly swung to the opposite conclusion: “if you felt so good about the test, you definitely bombed it”.

It’s a dumb paradox, but there it is: I wouldn’t be surprised if I got >240, so I wouldn’t be surprised if I got < 220

The truth is, whether I bombed it or not, my score will be 10 points higher than I deserve. I lucked out with my test. It played to my strengths: very, very minimal biochem (4-5 questions total), tons of genetics and neuroanatomy (my two best subjects by far), what appeared to be the entirety of the OB/GYN shelf (?), and even a couple of questions that I could’ve sworn were on Step 2.

So as much as I love complaining about the NBME – if my score sucks, it’s on me. I couldn’t have asked for a better test, and that fact makes the waiting bearable.

(Meanwhile, I started my Family Medicine rotation. So far, Family Medicine seems to be 50% constant awesomeness, 40% riding a bus, and 10% getting up at 4:50am to catch it. The 4:50 am part is pretty inflexible, so I’ll call it quits on this entry for now. Thanks again for all the well wishes!)

USMLE Week 5: Eh, Good Enough.

So after that mini-mental-breakdown of a practice test, I regrouped.  I montage-ed.  I set out to target my lowest-scoring subjects, grudgingly relearned them from scratch, ultimately spent more time alone in my room listening to morose music than I did during my last major break-up, and then proceeded to score, on two separate tests, just flat-out ridiculously higher.

… which – thanks in part to my newly-acquired Biostats knowledge (see: “lowest-scoring subjects” above) – I now know says more about just how poorly designed this test truly is than it does about how talented I may or may not be at short-term memorization.

(Okay, calling the USMLE “poorly designed” might sound a little harsh and high-minded – but when the NBME is purposefully distancing themselves from the notion that it’s an “achievement” test - in other words, that the exact scores mean anything – preferring instead to categorize it as “minimum competence”, and then still steadfastly reporting 3 significant figures?  At the steep end?  All while knowing that they’re handing out these career-determining judgements to the most self-absorbed, breakdown-prone students in the world?

… if that’s not poorly-designed, it’s at the very least disturbingly cold-hearted.)

And while I’m relieved as hell about scoring better, the relief is transient and the tiredness is a slow burn.  I’m forgetting more and more while caring less and less.

The result of adding this kind of burn-out to the general theme of my Step 1 study plan (which, FYI, would be most appropriately titled “Ways In Which I Helpfully Verified Common Wisdom By Ignoring It Entirely” - subtitle, “Somehow, It Went Poorly”) is a schedule for the last three days that looks something like “do stuff, but not too much or too little”.

I guess I will probably go through my flashcards again.  Or my notes?  Or re-listen to the recording I made of me reading First Aid.  Or learn to juggle.

I DON’T KNOW.  THERE ARE OPTIONS.  It’ll work out – and someday, as a commenter recently reminded me, there will be happiness again.  (Seriously, thanks for reading/tolerating self-absorbed posts like this, you guys.  Thursday can’t come soon enough.)

Meanwhile, Here Are Some Awesome Step 1 Resources Buried Deep In The Depths of The Internet: 

• - Compiled USMLE Step 1 Mnemonics
• - Protein Synthesis Inhibitors: Never Mix Them Up Again!
• - Virology Cheat Sheet - pretty great starting point, and well-designed to boot.
• - The Ultimate Guide to Gastrointestinal Hormones - Dude, seriously, this guy can make a table.
• - Confidence Intervals vs P-Value 
• - Everything I Need To Know I Learned From USMLEWorld - Where has this blog been all my life?
• - Goljan Flashcards (or here, a more selective set strictly from the Goljan High Yield document everyone raves about but never links to.)

USMLE Week 4: A Light Update

… So that happened.

For my more visually-challenged readers, that disturbing sound you just heard was the sound of an NBME practice test exploding me into tiny bits of sub-par, clearly less-than-average, horrifyingly-close-to-my-pre-studying score self.

IT’S LIKE THE NBME DOESN’T EVEN CARE THAT UWORLD THINKS I’M SMART.

IT’S ALMOST LIKE THEY’RE RUN BY TWO SEPARATE COMPANIES OR SOMETHING.

(Yeah, I know statistical variation is a thing.. but I’m not willing to attribute a difference of almost 40 points to it.)

Luckily, even though I’m studying in the middle of Abandoned Rural America, I had a friend who was willing to listen to my hysterical panic attack and help point me towards a rational plan for the next few days.

So instead of following my regularly-scheduled Gut Instinct of Crazy (crying, staying awake for 120 hours straight, emailing the dean, and then pushing back my test date) I will instead follow her advice and spend the next few days addressing specific areas of weakness in a logical order.

Like a smart person would.

All of this to say: This blog will be taking a minor “crisis-mode” break until the 21st.

The Worst Mnemonic Ever Made

 

First Aid for the Basic Sciences: Embryology chapter

… Seriously, First Aid for The Basic Sciences?  

… Seriously?

USMLE: Week 2

After multiple half-hearted attempts at writing this update, it looks like I’m kidding myself if I think it’s going to be coherent   I give up.  Just consider the lack of editing a testament to what studying is doing to me, please.  I am bleary-eyed and anergic to caffeine.

1.  My Step 2 CK score came in!  And I got my goal score: 200-and-Not-Outrightly-Memorable-In-A-Bad-Way points.

Seriously, I was dead-average and thrilled about it.  (Though – to be fair – I originally thought ~220 was average, which is why I was probably so thrilled to see that I got a 237.  Took me a second to parse that 237 was written twice because it was also the current Step 2 average.)

(By the way, did I just make up the “220 = roughly average” thing?  Was it ever true?  Is it something a med student told me years ago that I just internalized as the gospel truth?  Or are med students getting smarter?)

But, okay, DONE.  Nothing more to say on the subject.  No more speculation.  Back to Step 1.

2.  ”The best step 1 prep is to study hard for the pre-clinical tests.”  I can’t believe this saying actually turned out to be true.  I mean, sure, it makes sense, but I still thought it was mostly just a clever way for M3s and M4s to sound haughty when asked for advice.

All I know is that as an M1, I literally studied myself into an injury during Microbiology – probably the hardest I’ve ever studied in my life – and.. holy crap, I retained that information!  Even though it was all just random association.  It was amazing.

And I’m not saying that having a near-mental-and-physical-breakdown was “worth it”, exactly, but –  I scheduled myself 48 hours to review micro and only had to use 6.  So, time-wise, I guess overstudying for M1 Microbiology was as “worth it” as a near-breakdown is ever gonna get.

I just wish I could say that about the rest of the Step 1 subjects. Looking at my QBank breakdowns, it’s patently obvious that I barely passed M1 Embryology.  At the time, I just didn’t feel motivated to learn, and now I’m paying for it.

Actually, not only did I not feel motivated to study Embryo, but I distinctly remember explaining to someone that “You know what?  It doesn’t matter.  The only people who need to learn Embryology are future pediatricians.”  (Yeah, you tell them, M1 Action Potential!  … those.. future.. pediatricians…)

NO. BAD. Stop that RIGHT NOW, Former Me.  I am from the future and I am here to tell you are wrong.

But, too bad, I don’t have the time machine necessary to knock on my former self’s door and forcibly cancel her Netflix subscription, so instead I’m bitterly studying embryology 4-5 hours a day just to break even.

(Yes, I know it’s not “high-yield” for Step 1, but if I don’t learn about the embryonic origin of cleft palate anomalies now, when will I?  I made my bed and now I have to lie in it, etc.)  (Besides – for all I know, Future Pediatric Resident Me does have access to a time machine – and I really don’t want her to knock down my door to cancel my Netflix subscription.)

3.  Immunology: is, however, still stupid. 

4.  Stuff That Doesn’t Fit Anywhere Else:

• First Aid 2013 is a huge improvement from 2012.
• USMLERx “Flash Facts” has, by far, the worst interface and programming of anything I’ve ever regretted paid money for.
• That said, the USMLERx QBank is actually shockingly good – memorization-wise, it’s unbelievably helpful to have a picture from First Aid and page number for every answer explanation.
• I bought an extremely comfortable pillow and it was a major time-management mistake.
• Picmonic is new and brilliant.  I bet it’ll catch on as fast as Pathoma did.
• I am forcing myself to limit my prep books to 2 per subject, and it’s a daily battle.  This had better be good for me.
• I should have quit caffeine 3 weeks ago.

How the USMLE Tried to Kill Me

OK, yes – it’s a mistake. I know it’s a mistake, but there are certain things in life where you know it’s a mistake but you don’t really know it’s a mistake because the only way to really know it’s a mistake is to make the mistake and look back and say ‘yep, that was a mistake.’

- Lily, How I Met Your Mother

In the early morning hours before my Step 2 exam, I woke up, peeked out the window, and couldn’t see my rental car.  This induced mild panic until I took a closer look and realized that, in fact, my entire driveway appeared to have been turned into an impromptou snowdrift.

This was concerning.

I was still hoping for two more hours of sleep, but I sat up and checked the Prometric website anyway. It didn’t mention any cancellations, so I thought, “hey, maybe the snowstorm isn’t actually that bad!” and went on to check the weather – you know, just for validation that driving 2 hours east to the Prometric center wouldn’t be a big deal.

And after punching in the zip code, this is what weather.com told me:

THANKS A LOT, WEATHER CHANNEL. 

So there I was, at 4am, torn between Possibly Dying In An Icy Car Crash or being sensible and simply rescheduling the exam

Naturally, after a lot of guilt and soul-searching, I decided the only responsible choice was to leave immediately.  After all, I figured at 4 am, no one would be on the freeway yet, which would drastically reduce my chances of dying!  And by leaving with four hours to spare, I could – if necessary – drive at 30mph and still make it on time.

(Besides, it wasn’t like I was going to be able to get back to sleep at that point.)

The roads turned out to be icy enough that driving 30 mph for 3 hours was actually the correct decision, so that’s what I did.  As a precautionary measure, I threw at least 9 blankets into the backseat of the toyota, a flashlight, and some poster-board (for rescue signs, or impromptou pep ralleys, I don’t know) and headed to the interstate.

On the way, I got well-acquainted with a little yellow light on my rental car that occasionally blinked me friendly reminders about imminent doom.

“DEAR DRIVER, IF YOU DON’T ABANDON THIS FOOLISH MISSION IMMEDIATELY, YOU ARE AN IDIOT AND I HATE YOU.” – My Toyota’s Friendly Anti-Skid Warning System

But seriously, it was fine.  It may not have been fine if I had left any later than 4am (ice + skidding + other cars = no thanks), but my Prometric center was open and I’ll be damned if I was going to spend one more day studying – let alone the 2 weeks it would probably take them to reschedule me.

Oh, and Step 2 itself? Pretty anti-climactic considering the sheer adrenaline required just to get there.  It was hard to work up any actual anxiety for multiple choice questions after having survived the “deadly storm” on the interstate.

And now guess what time it is?

Time to study for USMLE Step 1, which I take in 7 weeks!

Just kidding.  I’m taking at least a full week of vacation first.

(… At some point, I will probably have to write an entry on why I decided to take Step 2 before Step 1 – but the short version is “my school’s schedule” + “my stubbornness” is sort of a winning combination for this type of thing.)

Potassium Limericks

Based on the premise that it’s easier to memorize rhymes than kidneys.

In hypOkalemia, medics
should first suspect loop diuretics,
steroids used thoughtlessly,
Magnesium paucity,
Or any cause hyperemetic.

Total parental nutrition
or maybe C.A. inhibition!
Villous adenomas
or DKA comas
Or hyper-adrenal conditions.

For excess potassium terror,
It’s renal OR adrenal failure
Succinylcholine, most types of gangrene,
or a digoxin OD (though that’s rarer).

Or SHH syndrome which can be treated
with fludrocortisone taken as needed!
In long-term; kayexalate
But now, Ca+ gluconate
And furosemide here can’t be beat..ed.

(… okay, I know – but hey, I tried.  HUMANITIES IN MEDICINE, folks.)
*drops mic, spreads arms wide, walks out backwards*

What I (Apparently) Learned From Gross Anatomy

Much like every other bit of note-taking I did in first year, I don’t remember writing this. I just found it on my computer while I was trying to reorganize something else.  

Accidental productivity is the best kind of productivity.

- If you get a knife wound, that sucker is definitely going to go through a nerve and leave you with a convenient functional deficit.

- Sensation around the umbilicus is mediated by T10.

- The lesser thoracic splanchnic nerves are not part of the celiac ganglia – common error.  Instead, they synapse in the aorticorenal ganglia and contribute to the renal plexus.  (Suprarenal medulla, however, is still greater thoracic splanchnic).

- If you have an ulcer, it WILL eat a complete hole not just through the appropriate part of your digestive system, but also through the major artery running behind it.  And then you will hemorrhage and die.*

- The Inferior Vena Cava is off-center – it’s on the right side of the abdomen.  Therefore, venous channels on the left side need to have longer venous structures to drain to the IVC.  That’s why the left inferior phrenic vein, left suprarenal vein, and left gonadal vein all drain into the left renal vein, while their right-sided counterparts drain straight into the IVC.

- If they use the words “Ribs 9 through 11″ , then (spoiler alert): the spleen exploded.

- The esophagus is crazy intimately related to the posterior part of the pericardial sac.

- If the question stem involves a surgeon, he performed the procedure correctly.  If there’s a resident or intern involved, there’s a 90% chance they killed the patient.

- The ligamentum arteriosum (vestige of ductus arteriosus) is closely related to the L. recurrent laryngeal nerve (because it loops around the aortic arch, and the ligamentum arteriosum connects the aortic arch with the left pulmonary artery.

(Actually, that last one should become an ingrained call-and-response.  ”You say ‘ligamentum arteriosum’, I say ‘left recurrent laryngeal nerve!’”  Enjoy shouting it at parties!  PEOPLE LOVE THAT.)

*  … actually, err, this does happen in real life. I re-read it and I was all, “ooh, prescient!”; then I realized my M1 self was almost definitely being sarcastic.  Take that, M1 self!  NOT SO SMART NOW.