Reflections on Head and Neck

My name is Derrick Antoniak, and this is my blog about being a first-year medical student.

I feel like so many interesting things have happened since my last post, so I will list as many as possible and do none of them justice.

So our dissecting group really has become pretty close. We sit for hours at a time picking fat and connective tissue from a cadaver we call Bootstrap, and I guess that experience, along with the solidarity that comes from going through a difficult life experience together has really put us in what Seinfeld referred to as the 'relationship time machine'. In the five weeks we've known each other, we've shared some good healthy laughs, some dry heaves, occasional tears, and covered the entire spectrum from the lightest to the heaviest moments. About two weeks ago Kylee told Tony and I that she was glad we were a group. The silence that followed prompted some laughter and teasing, but, in reality, I know that we get along well and genuinely care for each other, and I enjoy coming to lab to work with them every day.

Meanwhile, back in the real world, we had an exam coming up. The timeline went as follows: Luke and Janel's wedding was the Saturday before, and it was a blast. It's strange to be a full-blown adult, but I have some great friends that I know will be a part of my life forever, and for the short time I was at the wedding, we rocked it out pretty good. The next morning I got up and ran the corporate cup 10K with Joanna (and by with I mean far, far behind), had lunch at Amarillo, and then went to the gross lab to meet with Kylee and Tony for a review session that was too annoying to finish with my lost voice from the wedding. By Monday, my lost voice had turned into a cold, and its timing could not have been better with the exam looming. I finished the week out strong, though, opting to study most of Friday evening instead of attending the debate-watching party at Joanna's work. I woke up early on Saturday, ready to dominate. Unfortunately, Binhammer and company had different plans for me in the form of an essay question that completely caught me off guard and most likely reduced my exam score significantly. I left the lecture hall knowing that I had passed the exam, but knowing that I hadn't done as well as I wanted to.

As I was walking to my car, though, I was thinking about all the times I had heard the term 'head and neck', not only these past three weeks, but also the dreadful anticipation of 'head and neck' during orientation and the first two weeks of class, and also from the M1's and M2's I had talked to in my interviews both in 2007 and 2006. Dr. Binhammer told us of the many people around campus that say if you can pass 'head and neck', you've got your MD. I can even remember as early as 2005 my biochem professor at UNO telling me about this rite of passage in med school called head and neck.

So I left there not wanting to let that moment pass me by lightly. I had completed the unit, taken the exam, and in all likelihood passed it, and I had sort of the same feeling that I described after the white-coat ceremony, like 'I'm here, I'm really doing this thing that I looked forward to for so long'. So to celebrate, Joanna and I walked door-to-door handing out republican party voter information (slightly less intense than the liter-chugging-contest my classmates opted for at the Crescent Moon, but as anyone who heard Michelle's 'Heads Carolina, Tails California' speech would appreciate, I just wanted to be with her wherever we were).

Test 1 Grades and LCE Day 1

My name is Derrick Antoniak, and this is my blog about being a medical student.



The College of Medicine decided that we would get our exams back on Fridays, so there was a predictable rush to the mailboxes (tests are returned via campus mail, and all 132 of us have mailboxes in about a 15 foot space on the wall of boxes) Friday morning, and I could not help but take part. Long story short, I did fine. Anatomy is one of five 'cores' that we have to take this year, and that exam was one of four that we have to take for this core. So there are a lot of other pieces to pay attention to.



One of those other pieces is called the 'longitudinal clinical experience' (LCE), in which we are assigned a preceptor in whose clinic we work five times per semester for a pass/fail grade that is factored into the Integrated Clinical Experience core. Today was my first day of LCE, and I was far more excited for today than I was for the first anatomy exam.



My preceptor, who I'll call Dr. R, runs a tiny pediatric clinic in South Omaha. She is a very nice, very short, sort of middle-eastern looking woman of about 40(?) years of age. I arrived a solid ten to fifteen minutes early, wearing my shirt and tie, white coat, UNMC name badge, stethoscope around my neck, and some other tools in my pocket (tendon hammer, tuning fork, physical exam handbook, etc.). In about 2 and a half hours we saw three kids, two of whom were brother and sister sharing the same bacteria.



I sat down on the little stool with the wheels like any good doctor would, pulled my pen out of the breast pocket of my white coat, clicked it once, and started the interview: "So what brings you in today?" Unfortunately, this is a small clinic. Dr. R has seen this woman and both her kids about once a month (at least) for the course of their little lives, prompting the 'my kids are sick, you idiot' look from the mother. More questions: How long has he been sick? Oh, discharge from the nose? How long for that? Any cough? Sore throat? Fever? Any other symptoms? Then on to the exam, and at this point I am just following Dr. R, who is trying to show me the tympanic membrane (eardrum) through the otoscope, but all I can see is hair and earwax. Kids don't stay still for long, so we're trying to hold his head, and finally she's pointing out the 'cone of light' that indicates a normal eardrum, and I can see it, but I doubt that I could have found it myself. The process is complicated by the fact that we just learned some ear anatomy, and two different professors mentioned that kids have short auditory canals, so you have to be careful not to stick an otoscope through their eardrum (no pressure).



What's scary about all this is how essential it is. Middle ear infections (the type you can diagnose by looking at the tympanic membrane through an otoscope) must be actively treated because with the middle ear's proximity to the brain, they can lead to meningitis. So it is absolutely necessary that I learn this skill. On the bright side, to get from where I am today to Dr. Roy's position (licensed pediatrician working with no supervision) will take seven years, and I think I should have it by then.



So we had two kids with upper respiratory infections (URI), and we prescribed them both a cheap antibiotic and one of them some extra asthma medicine (some type of corticosteroid, I don't know the names). I went back to my desk, looked in the pediatric handbook, looked in the massive textbook of pediatrics, looked at a few point-of-care resources on UNMC's intranet, and all sources said that URI's are mainly viral and resolve themselves. Stumped, I asked Dr. R why antibiotics had been prescribed, only to find out that I had apparently missed something. The drainage from the nose was very thick, indicating probable bacterial involvement, and amoxicillin is cheap, and usually an effective first-line antibiotic.

So, not the smoothest first day, but I left with an experience to build on and some nice learning objectives to look up before next time. Meanwhile, back to the library and gross lab and hopefully home for at least the second half of the game.

Head and Neck

My name is Derrick Antoniak, and this is my blog about the first year of medical school.

Well, we've moved on to unit two, head and neck. It just so happens that yesterday was Joanna's birthday, so I had some people asking me questions about school, and I also talked to my cousin Tom on the phone, and he was asking me how things are going. People really react to the things we are doing in class right now, so I thought I should write about some of them here.

Monday began the face dissection. My group gave me the privelage of making the skin incisions, which involved cutting our man with a scalpel from the center of his forehead at the hairline, down the forehead, down the center of the nose, through the center of both lips, down the center of the chin, all the way to the base of his neck. Then I cut around both eyes, his nose, and down the sides of the head just in front of the ears, and we skinned all but the nose to expose muscles, arteries, veins, and nerves. After lab, the instructors went back in and cut off the top of everyone's skull to expose the brain. Being the over-achievers that we are, Tony (a group member) and I were in the lab later that night and had the good fortune of witnessing this process on a few cadavers. They use a power saw to get most of the way through the bone, but, in order to not damage the brain and its covering, the last layer is broken off with a hammer and chisel. The smell of the bonedust and the sound the skull makes when cracking under the chisel are by far the worst things I have witnessed in the lab yet.

Tuesday we returned for a dissection called 'cranial cavity'. We really spent most of our individual time trying to straighten out the muscles of the face, waiting for the instructor to come remove our brain. The brains have to be used in the spring semester, so rather than let us remove them and risk damaging something vital, the instructors come to each table and systematically remove them, starting in the front and working their way forward, pointing out, and then cutting, each cranial nerve in reverse order. Between the mangled faces, handling the brains and pieces of skull, and the rather large amount of juice left behind in the cranial cavity, it was too much, and for the first time (that I know of) we had people going to the locker room to get sick. Kylee (another of my group members) had a pretty forceful gag (that only by the grace of God did not have any vomit behind it) that sent her to the locker room and sent me and Tony laughing so hard that we both were crying.

Wednesday's dissection was titled 'orbit', and the first line of the lab manual directions had me cutting bone with chisel in order to get into the cavity of the head that holds the eye. There is a 'superior approach', in which I had to cut through the roof of the orbit (part of skull), and expose many of the nerves, arteries, and muscles that make eye movement possible. In the 'anterior approach', Tony had to cut through the eyelids, dissect some of the structures involved with tear production and secretion, and, ultimately, remove the eye itself. Kylee was able to juggle the directions for both of us at the same time, and at the end she wanted to be the one to remove the eye and cut it in half to get the lens out. I am stating everyone's role because I fear that our group of four may become a group of three. Our other member didn't seem (to me) like she was ready to quit, but she has been absent two days in a row, and I know she has a young baby at home. We feel like we didn't even have a chance to try to help her work through it. We'll see.

In other develpments, we still hadn't named our cadaver. Towards the end of lab today, our guy was laying face up, with his head sort of propped up on a piece of wood to facilitate working on his skull. For some reason, with his face in the condition it was in, he looked like the dad from Pirates of the Carribean, (Bootstrap Bill Turner) so we decided to call him Bootstrap (this is not a disrespectful practice; it is an affectionate name for a man to whom we inevitably feel extraordinarily close).

Exam 1 in the Books

My name is Derrick Antoniak, and this is my blog about being a first-year medical student.

Well, yesterday was the first exam of medical school for the 132 members of UNMC's class of 2012. So, to recap the first two weeks:

On day 1, we met our cadavers, then proceeded to dissect the entire back, scapular (shoulderblade) region, pectoral region, axilla (armpit), arm, forearm, hand, and fingers by the end of week 1. The first two weeks also included lectures on fertilization and early development, along with lectures covering each of the body regions dissected in lab. Living anatomy, another significant portion of our learning experience, is an exercise in which all 132 of us take our shirts off in the amphitheatre and palpate (fancy word for feel) muscles, nerves, arteries, bony prominences, etc. in each of the body regions being covered in lab on a previously chosen partner. In addition to all that, we've had some afternoon lectures and small group meetings covering health care quality and professionalism.

The test was scheduled for Saturday morning. Very few people acted real confident that they understood the material and knew they would pass the exam. The levels of stress, though, varied pretty significantly amongst my classmates. Some flat out said they were probably looking at the 'five year plan' (if you fail, you repeat the first year). That's the high end of it, but I assume that the entire spectrum of pre-test anxiety was well represented. For my part, the night before the exam I went to UNO at 5 for the chemistry department's 2008-2009 kickoff (there was free pizza), after which I spent about 3 hours with Joanna delivering Johanns for senate signs to the good little republicans who had requested them. An ill-advised trip to Taco Bell, about another hour of liesurely review, and I fell asleep at Joanna's house around 11.

I woke up at Joanna's the morning of the exam about 5:15. I went home, showered, dressed myself for success, and made my way to school. I was in group A, which meant that I had to report at 8 for the written portion of the exam. Group B reported to the gross lab first for the practical exam. We had 2 hours 15 minutes to complete about 45 or so multiple choice questions, one page front and back of short answer, and two essays. The questions were tricky, but manageable. I finished early, so I had to go wait in the hall outside the gross lab until the switch was to take place. They try to prevent interaction between the two groups between the two portions of the exam, so we sort of get herded around the halls down there in a specific pattern until we finally got inside the lab and positioned at our tables. The way it works, if you've never taken a lab practical, there is a computer hooked up to a sound system in the lab. Every minute the computer sounds a bell. When you hear the bell, you move to the next station, read the question, look for the pin in the cadaver, and try to answer the question before you hear the bell ring again. A little twist: after question 15, the bell rings, you take your shirt off, put down our paper and go sit down in the 'waiting chair'. The bell rings again, and your living anatomy partner (who is mandatorily next to you) takes off her shirt and joins you at the waiting area. The bell rings again and you both go into the first living anatomy cubical and one of you grabs a card: "Demonstrate the bony prominences of the shoulder." Before you finish the bell rings and the other partner grabs a card: "Draw the flexor retinaculum on you partner and its bony attachments. Explain what you are doing." Before you finish, the bell rings (or even worse, you finish first and stand there feeling awkward because you're topless, and the grader feeling awkward because he/she can't let you see how many points you lost or why on the little clipboard) and you move to cubical two. There are a total of four cubicals for living anatomy. After the final bell rings in cubical four, you walk out and put your shirt back on. The bell rings and one of you moves on to station 16. The bell rings again, and the other partner follows suit. There are a total of 55 stations, and, other than the living anatomy, I am relatively certain that I scored very well in the lab. There was not a single cadaver whose pin I could not identify, and there was not a single x-ray in which I could not identify 'the structure at the tip of the green arrow'.

Well, this is getting out of hand, so I'm going to stop. We get our grades back next Thursday, so I'll post mine at that time. Meanwhile, we start dissecting the face tomorrow, so I think it's going to start to get a little tougher for people to cope in the lab, but we'll see.

Reflections on Week 1

My name is Derrick Antoniak, and this is my blog about being a first year medical student.

Well, today is Labor Day, a day that has always been special to me since I've traditionally been a construction worker looking forward to the end of another hot summer of hard work. This holiday weekend, though, has been mostly built around my study schedule. In fact, I've been watching the dog for my mom while she's out of town, and Joanna's been working pretty much day and night between her two jobs, so aside from the Husker game, I haven't done much at all.

With the holiday today, we had a scheduled session in the gross lab Saturday morning, which turned out to be very worthwhile. Many people left town for the weekend, so with the lab less crowded we got more time with the instructor in those two hours than we got on Tuesday through Friday combined. We finished the dissection of the hand, which means that with the exception of a demonstration on joints, we are done dissecting for the first exam, which is this coming Saturday.

I feel good about school right now. I think the pace is good; we're moving quickly, but not too quick for me to keep on top of it. It's nice, of course, not working. We have five mornings (8 to 12) and two afternoons (1 to 3 or 4) scheduled each week, with the rest of the afternoons and weekend unscheduled, so I haven't done the math yet, but I may be putting in about the same amount of total hours that I was between school and work as an undergrad. The stress level is admittedly higher, but so is the motivation and interest.

Today I am actually reading the anatomy textbook for the first time, which brings up another interesting point. We have more tools for anatomy than we can possibly use. There are dozens of atlases, we have a textbook, a more concise review textbook, there are anatomy flash cards, online we have hundreds of images, slides, radiographs, etc., there are power point lectures online, along with hard copy handouts for each lecture, in the lab there are videos showing dissection of each body region that we're working on, boxes of bones, and of course, the cadavers themselves. It's been fun to have some autonomy in deciding which study aids I want to use, and when and how to use them.

Anyways, back to the grind.