Oh... So that's where that came from?

Above: My old workspace in the Aquatic Ecology Lab, during my old research days at the University of Illinois, Summer 2007.

“To me it was obvious, we can’t improve survival unless we test new treatments against established ones.”
- Dr. Scott Ramsey, M.D. in the New York Times.

Looking through a First Aid book the first few times may be daunting: in almost 400 or so pages, the book tries to compile the whole nine yards about the human body. And in order to compress all that information, the information comes in quick-n'-dirty tabular form, where usually the information can only be understood if school had taught that concept properly (at least with the way I studied... so I thought).

But amidst this compression, I think sometimes us med students neglect to acknowledge how much effort and time actually goes into the conclusions that is now common knowledge for medical students. At a point, what we sometimes think now is a typical fact, was previously a conclusion that was came upon due to a series of clinical trials or scientific experiments. Who knows how many studies led toward a single line of "common symptoms" that us clinicians (with the MDs, DOs, and others) need to know.

In the series called the "Forty Years War" in the New York Times, I read a few weeks ago about how getting cancer patients to participate in studies has been quite a fight. From a patient's point of view, initially, the costs mount up quite well: the treatments aren't guaranteed to work, there might be risky side effects, and there's quite a deal of "red tape" and extra meetings that the patient needs to participate in order for the researchers to gather data.

For instance, in one of the latest New England Journal of Medicine articles that I've read, 3200 patients were selected for a study. Even before the actual treatments and data collection were underway, 3059 of them were already excluded (everything from not meeting minimum patient criterium to not even wanting to be a part of the study). That left 141 people to represent the thousands of people with similar conditions in the study. That's quite a small sample, but the researchers did the best with what they had.

In the world of research, the smaller the sample size, most probably the less powerful the findings. I don't know we could exactly fix this problem though... the benefits are there, but I can definitely empathize with the patient, and their concerns. However, they are the ones that hold the power towards the progression of treatment in the world of medicine.

Using lab animals just isn't the same as using good old 100% human beings.

Source: The New York Times & The New England Journal of Medicine

Valuable Talents

Above: A former Cuban doctor continues his medical career as a nurse in the United States. From The New York Times, Maggie Steber, 8/4/09.

MORE PROOF THAT ANYONE WOULD DO ANYTHING
FOR A DREAM.

January 2009. I remember that one thing that struck me about the medical staff of Princess Margaret Hospital in Dominica was that the doctors were not just of Dominican descent. In addition to working with the natives, I also worked with a few Cubans, and not to mention an American, and a Filipino (that's luck!). I remember asking one of the Dominicans where he got his medical degree, and he told me that many of the Dominicans really don't go to Ross, but they head to Cuba to get their education. I'm guessing this partnership in medical education explains why many Cubans also found a place in medicine in Dominica.

August 2009. The New York Times featured in their Tuesday Science & Health section, an article about doctors who are fleeing from the political oppression in Cuba and heading for a life in medicine in the states. However, many of these doctors face the challenges that many IMGs face: a language barrier (see my previous IMG entry below) and board examinations that might feature knowledge that outdated textbooks in the Cuban system lack. I really enjoyed former doctor Carlos Domínguez's story about how he traveled to the United States in a boat that didn't have a reverse gear, because he knew he was never going to return to Cuba.

Working with the Cuban doctors during my fifth semester was quite a treat. When working with them, their enthusiasm for the field of medicine definitely showed through their willingness to teach (along with their patience for a set of medical students just bound to mess up). When observing one surgeon perform a hysterectomy, I can clearly remember how excited he was when he saw the patient's fibroid (an abonormal mass originating from the smooth muscle of a woman's reproductive system), and his eyes lit up exactly like a little kid in front of a candy store. After student presentations, the Cuban doctors were more than willing to announce their praise for the students and for the work that went into it.

I absolutely enjoyed working with the Cubans.

The thing I respected a lot about the doctors I worked with was their excellent bedside manner and the ability to speak with them on a first name (okay, semi-first name, because they had us put the doctor title in front of their first name) basis. They also were more than willing to crack jokes left and right to keep the mood light - for patients and for students. For me, it doesn't jive well that doctors from Cuba making it to the U.S. (many of them with great experience, work ethic, and strong motivations) are ending up not working at the level their title, and instead working in other positions in health care (e.g. nurses). Some even go on to work in other unrelated fields.

I understand that coming to the states for freedom is a dream... but there has to be a way for these doctors to be utilized. There's definite potential.

I don't know, perhaps this is a "Hail Mary" idea, perhaps they could be a part of a solution to cure our shortage of primary care physicians? From my experience, they do have the knowledge, the passion, and the ability to be a part of our American Dream of good health care. I don't think that their talents should be wasted; instead, I believe their talents should be refined.

Source: The New York Times

What's really behind your decisions?

Above: Ming Hsu, according to LASNews, one of the pioneers in a growing field called NeuroEconomics. Picture courtesy: Illinois Today.

One thing that I love about the University of Illinois at Urbana-Champaign, my Alma Mater, is the loads of Alumni publications that I recieved from the land-grant university, established in 1869. One of them comes from the college that my major (Integrative Biology) belongs to, called LASNews (LAS = Liberal Arts and Sciences). In it are loads of articles with updates on how the school is doing, what research is going on from the various fields in the college, and not to mention, the classic requests for giving back to the Alma Mater.

The front cover of this semester's magazine had a picture of a brain CT scan, with a stash of cash superimposed on it. The headliner goes something like this:

"Money on the Brain: THERE'S A LOGICAL DECISION WHY WE SOMETIMES MAKE IRRATIONAL DECISIONS - ITS HOW WE ARE WIRED."

Economics, to me, is quite an interesting subject, as it can be related to every single day of our lives. Why? At least in high school, I learned that the field has a lot to do with how we consider the benefits and costs of decisions in order to make them. Ming Hsu, as featured in this article took this decision making further: looking at how different parts of our brain contribute to that decision making.

As medical students: our dip into neurology involves which parts of the brain affect different aspects of how our body is regulated, everything from the involuntary (breathing, heart rate, sensation) to the voluntary (movement of our limbs). However, most of the neuropsychology research that I did in undergrad really didn't make the cut toward the medical curriculum.

The brain is one of the most perplexing things known to man. We know already that there are centers for many of our different brain functions, such as the amygdala for our emotions, our hippocampus for creating new memories (go rent Memento, one of the most realistic examples of amnesia on the big screen), and the hypothalamus, which regulates many of the processes that go on within our bodies without us even knowing it. Even broader areas of the brain have been loosely defined, such as the left side, for most of us, the center of calculation, while the right side of the brain has been shown for more abstract, artsy thought.

Through a use of various neuroimaging technologies (where basically the brain lights up as different colors depending on how active each part is) and putting people through standardized decision making (such as the reknowned economics ultimatum game), Hsu can see how different areas of the brain contribute to our daily tasks of making decisions. By combining economics, neuroscience, and psychology, he has become a pioneer in a new field called neuroeconomics.

I'd love to see what conclusions Hsu has... maybe finally after some type of traumatic event or neurodegenerative disease we can have a better idea how decision making may be affected. We know that some diseases affect specific areas of the brain. Who knows, perhaps it will be more comforting to the families of brain trauma patients, if clinicians could give them a better idea of what types of cognitive challenges their loved one may face. They would know when the decision was considered appropriately and when exactly to assist in making appropriate decisions, allowing the patient a degree of independence & confidence (instead of thinking that every moment their loved one was incapable of making decisions for themselves).

With a little predictability due to neuroeconomics, us clinicians could make life a little less frustrating for patients and their families.

Source: LASNews Magazine, University of Illinois at Urbana-Champaign.

Green Yarn

AT PMH, ALL YOU

NEED TO KNOW

IS THE

RAINBOW.

My very good friend Neal, from Champaign, IL asks:

"I'd love to hear about the medical gadgets and technology you're using [in Dominica]. Which do you think are cool? Are there old fashioned devices/new ones?"

On Friday of this week, President Obama named a Harvard professor (Dr. David Blumenthal) to take over the modernization of information technology (IT) record keeping (from the days of paper-domination) in the United States (with a price of about $20 billion dollars). For everyone, I'm sure you've seen those tabular sheets that your doctor probably carries around in a light manila folder whenever you're in the office. When you're talking to him or her, it won't seem like he's trying to actually fill it in properly: He's not circling all the items, using handwriting that's not much better than the output of a seismograph during an earthquake, and not following his mother's advice by writing outside of the lines. That's the issue with record keeping: it's hard to keep it uniform so that when another doctor that gets a hold of the records, he or she can understand your situation.

Well, Neal, you probably are still wondering if I'm ever am going to answer your question, but I mentioned the above to create a dramatic contrast of the level of technology simply based on organizing critical patient information.

Like I said above, it's all about the rainbow. At PMH, record keeping is definitely old-fashioned. When handed a patient's records, I don't get a manila folder here. I end up with a pink (or sometimes blue, or sometimes tan-ish) colored folder that's seemingly constructed out of (go figure) construction paper. Holding together the massive amounts of colored paper that are inside are pieces of green yarn. Inside, the paper forms are definitely consolidated to a small set: Green is usually for doctor's notes, Yellow is for blood tests, Manila is for admission information, and Red (I think) seems to be more admission information. The best part is that there's no standardized chart on the Doctor's / Nurse's Notes. So, aggravated by the seismograph-like handwriting, it makes it more tough figuring out abbreviations or organization of critical information when trying to report back on the patient. As you can tell, Neal, to me, record keeping is one of my biggest concerns with technology for the Dominican Hospital (and to me, probably the easiest to set up: get together and IT department and wire up the hospital).

With that out of the way (and knowing you're an engineer), I think one of the best pieces of technology actually is something I carry everyday. You've probably noted your doctor ask you for permission to look into your eyes during a general check up and he'll flash a light into your eye and look through an instrument right into your eyes. This baby is called an ophthalmoscope. Looking into your eye and visualizing the rear wall of your inner eye (the retina) can be very diagnostic of signs of conditions that plague many of us (i.e. Diabetes or Hypertension). However, the ophthalmoscope I carry around (the WelchAllyn PanOptic, with a more detailed link below), is about 3 times as large as a standard ophthalmoscope you see in a typical Doctor's office. Using refractory technology, it actually gives a Doctor 5 times the viewing field of the rear of your retina than the standard opthalmoscope, allowing someone like myself to catch abnormal changes in your retina more easily.

Otherwise, PMH isn't really fully featured with technology, to be honest to ya. You'll find good, up-to date standards in the operating room (i.e. finger-placed optical detectors for vital signs such as blood pressure and oxygen saturation), also there's standard tech such as X-Rays and (I think a CT machine), but its hard to find even computers to organize patient data or records of who has been admitted in some of the wards. Another stark contrast occurs when noticing that there's no TVs to keep patients occupied as they lay in the wards.

It sounds like technology acts as a detractor to the whole experience, but I totally believe that technology can only be as good as the doctor that uses it him/herself, and the hands-on experience with patients (the people who truly matter) is something I can take with me in the future. Trust me, when I say that the doctors at PMH are absolutely amazing as clinicians and also as teachers, because it's amazing what they can do even without the big-bucks technology we find in U.S. hospitals today. With T-19 days left until I return home, I'll say it before I forget: Thanks for Everything, Princess Margaret.

Hope this answers your question. I'm looking forward to another good prompt (it keeps me occupied). :D

Sources: RedOrbit, WelchAllyn

Lifestyles of the Fast & The Busy

Above: KFC in Roseau... in the foreground, the empty tables of the Roseau market.

"YOU ARE.... WHAT YOU EAT."

A few weeks ago, a new restaurant lit up its new fluorescent sign in Portsmouth. And on it was a big picture of Colonel Sanders in his red and white apron, tilted over and smiling. I have to say that the opening of the KFC is something that both was a win and a loss situation. On one end: It's great to have some real fried chicken in the area now, and to get dinner there could save one a few more bucks (along with time) over Subway. On another end: This stuff can kill you (if you eat it often enough, that is).

A recent report from CNN says the proximity that one is to fast food restaurants in their neighborhood is directly related to the occurrence of stroke. I don't know how much that really applies to Dominica (where there's only 4 total fast food establishments, 2 of them being Subways), but this finding in the United States is rather interesting. I guess then, that me, in my hometown back in Chicago, with 5 fast food joints within 1 block (let's see if I can remember: McDonald's, Burger King, Dunkin' Donuts / Baskin Robbins, Pizza Hut, and Nick's Gyros & More), I'm at a higher risk of stroke.

One of the most interesting points that ran across my head when I read this study, is when I read that socioeconomic implications weren't included. I gotta say that in the states that this might be the case: when someone wants some food fast, the best part is that it comes cheap.

However, living in Dominica, it seems different:
Fatty, greasy fried American fried chicken seems to be a commodity in Dominica.

Although KFC is faster than the Subway on the Ross campus, I've found out that its still not exactly as fast as it is in the states, but people are still there for the "fast food." Not to mention, seemingly with the hassle of shipping things over from the states & other various regional factors, not everything on the KFC menu you see in the states comes over here in Dominica. Case in point: every meal on the menu comes with french fries, unlike the standard homestyle options as presented in the states (you know, the cole slaw, the mashed potatoes, green beans, etc etc.... in Dominica, these are all separate options). In addition, the stuff is quite a bit more expensive than the traditional Dominican way of purchasing fruits and vegetables from the market and cooking it all by one's self. However although this was the case: the place is still packed with Dominicans (and obviously Ross students).

So, let's put it together: could the equation of Dominican Demand + KFC = Lesser lifespan of Dominicans?

I forgot to tell you one important thing... According to a BBC report in 2007, one thing that Dominica can lay good claim to is a large proportion of centenarians (22/70000, which is about three times as high as that of many developed countries). My university, Ross, is trying to figure out why this is the case. However, with the above story, is it possible to have an affect upon this proportion? Remember that before, there was only 1 KFC and that only appeared from what I assume (based on the decor in Roseau), in the last decade.

Like I said KFC's addition to Dominica has its good and its bad, but only time will tell to see how much affect it will upon the health of Dominica. It's something I'd like to see: the real effects of fast food damage on a Country's health over time. It could be bad, but knowing that there's still only 2 KFCs in all of Dominica, and with it being a "luxury" commodity in Dominica, I think that we'll still see more centenarians to come.

Don't get me wrong... I still dig the colonel, and it's quite good here in Dominica.... even with that risk of stroke. :D

Source: CNN

A Great Pianist in the Making

"HOW MANY FINGERS AM I HOLDING UP?.... TWELVE!"

Here's your homework for the day. Ask yourself, "What would I do with twelve fingers?"

I had to ask myself that when I was reading this article the other day. In January 2009, in Daly City, CA, Kamani Hubbard was born with not the typical 10 digits on his hands on feet, but instead: twelve. In medicine, we call this condition polydactyly (poly = many + dactyl = toes + y = condition). This type of trait actually runs genetically in the families (for you sticklers on inheritance, in an Autosomal Dominant form, appearing just about in family's generation), or can be a defect as a kid is maturing in his mother's womb. However, usually the extra digit or digits are usually either webbed together (syndactyly) or are non-functional.

BUT THIS CASE IS DIFFERENT... All twelve fingers and toes of Kamani's polydactyly are functional. He can bend them, squeeze them, flex them... do just about anything the other 5 can do.

Whoa. Totally awesome, huh? :D

Now,Imagine how much easier it is to grasp objects, or even play the piano. Imagine the type of control the kid can have over a baseball... He could even be a spokesperson for people across the country with similar conditions... just imagine the possibilities (including how many new pieces of bling he can carry on his fingers now :D). However, things come with their cons, right? Six fingers could literally be the target of bullying and teasing from his fellow classmates... Can he find footwear with a wide enough toe to fit the sixth digit (extra wide-width?)... How about gloves with six fingers for those cold months?

SO... WHAT'S THE GAME PLAN?

Due to the non-functional nature of most polydactylies, most of these situations end up with the removal of the extra digit. However, like I said, all the fingers are functional. If I was the doctor in the situation, I think I'd encourage the parents to keep the fingers. I can just imagine the kid growing up and asking them "Why did you cut off my sixth finger?" I personally would be shocked to hear that I had a sixth functional digit as a gift. And let's say that someone started making fun of me for my extra digit. I think I'd challenge them to a stunt or a task that I could do more efficiently with six. Then, I'd show them who's boss.

I'm getting ahead of myself - I never had six fingers. Here's the point. From my point of view, why rob a kid from a perfectly functional gift... it's literally like returning something that looks promising before even trying it. Give it a chance... like I mentioned above the possibilities are endless. I personally want to follow this kid to see where he goes, and for me, with a good assumption he has strong, encouraging parents, I'm already predicting quite, quite far.

So, back to the question: What would you do with twelve fingers? Your homework's due :D.

Source: KTVU San Francisco