The body electric

***Short one for the holidays!  Also full of oversimplified neurophysiology, not designed to be used as an actual source for teaching or research or anything.  I'm just a med student, not a teacher***

So, like most med students, I hated physics.  Sorry physics professors, that’s just the way it is: we all take your classes because we have to, forget it all, cram some of it back in for the MCAT, forget it all again.  No wonder we get really cranky when Neuroscience time comes.  For the not medically or biologically inclined out there: your nervous system is all about electricity.  Everything you know about the world around you, all your memories, feelings, sight, sound, touch, and taste – it all at some point in your body gets boiled down to an electrical current running through you.  I don’t say this to denigrate the breadth and depth of the human experience – I say it because it amazes me.  It’s a miracle – a full scale major marvel of the world that we are able to experience everything the way we do.  

It’s the holiday season and one of my favorite things to do is to listen to Christmas music – full rich brass quartets and eight part church choirs rendering the classis (with descents and harmony, of course).  To hear this music the sound waves have to travel from the speakers through the air, through my ear, eardrum, bones of the ear to a tiny snail shell organ – the cochlea.  Inside this is a membrane so perfectly tuned that when the vibrations hit this fluid-filled canal it causes vibration in a small area – an area that differs depending on the pitch.  So the soprano descent causes vibration in a different place than the tuba.  That vibration disturbs some cells, actually pulls open channels in their cell membranes to allow ions to flow in, converting music to a tiny electric current.  And no matter which cells, no matter how loud the sounds, the size of the current (amplitude for the nerds out there) never changes.  All the richness of sound, the variations of timber, pitch, temp, and volume are coded by which little cells light up and how often they light up.  Their little electrical signals travel to the brain stem, to be organized, categorized, sorted and perceived.  Incredibly, they pass through multiple nerves carefully placed just so for any point in space two cells will light up at the same time (one from each ear) and your brain knows what it means when they do – this is how you can find that band playing in the shopping mall.  Even more incredibly, when we hear even the simplest of musical sounds – a lone pianist for example – there’re are actually a whole group of tones.  When I play a note on a piano it sounds different from the same not played on a harp.   Again, we have to deal with physics, but this is because each instrument actually produces a specific set of extra pitches with each tone played – the harmonics.  This is how we learn to recognize different types of sound.   But somehow we know which pitches are the central ones and which are just harmonics.  Somehow the nerves all line up and we know where the sounds is coming from, somehow the pitches trigger the right piece of the membrane and connect to the right cells which our brain knows to perceive as music.  The fact that this works all day, every day is incredible to me. 

What to say in the anatomy lab

So yesterday we had a return visit from one of my most and least favorite of instructors.  Yes, he really is both.  On the one hand, he is plainspoken in a classroom that is often full of new and baffling terminology.  He is extremely interactive in his teaching, and after hours on end of PowerPoint lectures I really to appreciate that.  He always seems to understand exactly what we know and don’t know (this is an obnoxiously big problem in my classes so far, more on that another day).  However.  He tends to air his biases loud and clear, and often words things in ways that mange to be simultaneously offensive, human, and funny.    

This gets to the heart of one of the most difficult issues I’ve had with medical school so far: how do we maintain appropriate respect, teach professional behavior, and nurture compassion without stifling the human beings that we already are in a haze of serious tones and somber thoughtfulness?   An excellent example of this is the dissection lab.  It is extremely important to be respectful of our donors (the people whose bodies we are dissecting), and I never at any point in this post want there to be any confusion about that.  But the process of lab itself is very stressful for a hundred different reasons: being bluntly faced with a dead body, surviving your first few months in medical school, breathing all the preservative fumes.  And dissecting is not easy.  Sooner or later you look up at the clock and realize that for the past two hours your entire world has been narrowed to a few square inches of tissue in which you’re trying to sort out what’s important and what’s not and what you have in your hands mostly just looks like a mess.  My thumb was slightly numb and tingly for a week after I spent four hours doing the same motion with the same dissection tool.  In this situation you need some humor, some lighter conversation.  Whether it’s gossiping about your team-mates love lives or trash talking each other’s home teams, we can’t spend every second of our time in the lab being consciously respectful and survive. 

That doesn’t mean that anything goes, there are always lines.  But where exactly should we put them? What’s offensive and what’s not varies: person to person, place to place, day to day and throughout time.  I’m sure that if we polled enough people, we could find someone who thinks sports trash talk is too much, much less talking about sex lives over a dissecting table.  But more important is that these issues aren’t limited to gross human dissection.  In the lecture hall there are no patients, no bodies to remind us of the consequences of our speech.  Combine this with an odd tendency medical school instructors have to try and treat students as future colleagues (and sometimes, I think, a desperation to get a response from the sleepy hall) and we get these gems (paraphrased, of course):

“In pediatrics we have funny looking kids, he’s [a hypothetical patient in a photograph] a funny looking adult”

“This [part of the physical shoulder exam] is really fun, because they jump – because it feels really weird, you’re dislocating their shoulder.”

Both of these were very awkward moments for me.  On the one hand I definitely thought both of those things.  And I believe it’s important to take time to acknowledge such reactions, to recognize that we’re its natural to think and feel certain responses – appropriate or not.  This can help us sift through all the crazy things we do think and feel and help us separate what’s okay and what’s not.  On the other hand when there are instructors involved we should be more careful.  Can an instructor talking about irreverent and inappropriate responses help to facilitate important conversations about mental health, emotional responses and professional behavior? Yes.  Should an instructor be modeling potentially inappropriate responses without taking the time to reflect on and explore them? I don’t think so.  Because the bigger point is that these are just things I personally noticed.   What did someone else, someone with a different perspective, notice and think about that I didn’t, that no one pointed out to me or brought to my attention?  What did I accidentally learn?

Transporting Skulls

Context is everything.  While I’ve done some strange things in medical school, I usually do them in the land of the utterly bizarre: the gross anatomy lab.  No matter how taken aback you might be for an instant, in that room you have only to look around as you dig through the layers of the human body to remember that everyone there understands. 

Not so with transporting skulls.  I recently had the opportunity to take a human skull home from school to study for our anatomy exam.  Have you ever had the chance to look - I mean really look - at a human skull?  They’re infinitely more complex than I had hitherto imagined.  I recall a lot of talk in undergraduate anthropology classes about the foramen magnum (Latin for big hole) and its position leaving us telltale clues about the development of bipedalism.  Little did I know that this is “the big hole” because there are approximately a zillion small ones.  Yes, a zillion.  Most of them have specific names, too, so in an effort to help us learn all the ins and outs of these sneaky passageways each pair of students was assigned our very own skull. 

So it is that I found myself one day last week boarding a city bus line with a very peculiar box.  The box is gray plastic with egg-carton foam lining the inside to protect the bones.  It’s kept closed tightly with a giant rubber band – like the kind for newspapers or broccoli, but bigger.  On either side it sports a white label marked: “Human.”  This is, I assume, so that the skulls of all types can be kept in an orderly fashion when not being used.  The box does not fit in my tote bag, where I was planning to keep it hidden from the other passengers.  It goes in, but the top doesn’t close.  This leaves the label, “Human,” clear for all to read.  I would prefer that wasn’t the case.  Even though I’m doing nothing wrong I have a guilty sensation.  I expect to be pulled into questioning by the transit police for transporting human remains.  I try to think of how I will prove I’m a medical student when this happens.  My student ID doesn’t specify my program and it’s not like I carry proof of registration with me.  I have an anatomy syllabus and a copy of Grant’s Dissector - a manual on how to dissect a human cadaver - in my bag.  Maybe those will be enough?   I tuck my scarf over the box, hiding the box from view. 

As I stagger to the back of the bus, I set the bag down reverently, gently.  I recall thinking that anyone observing must think there was a computer inside – because really what else would the modern commuter be carrying that’s so fragile and valuable?  I, of course, know the truth.  I’m carrying so much more than a computer.  I keep my hand on top of the bag trying to protect it from falling sideways as the bus turns and stops.  I still envision someone watching me.  Deciding to search my bag that so clearly contains something of value, something possibly dangerous.  In the end of course, nothing happens.  Just as no one ever cares what I have in my bag, no one cares today.  No one pulls aside my scarf to find the “Human” label on the side.

In the end this is just one of the moments of medical education when you stop and think: how strange were the things I did today?  Not only did I have the opportunity to cradle in my hands the place that once held this person’s brain - the seat of all that they were - but I put it in a gray plastic box and hid it in a tote bag to ride the bus.