Mosquitoes

Since finding and buying liquid mosquito vaporizers, my life in Dominica has been much better. I have only had two bites since I started using them August. (As a comparison, I used to 6-12 bites PER NIGHT.) Well, Thursday night I got my second bite since I started using these amazing vaporizers. I think the mosquito decided to make me pay for not being mosquito dinner lately: IT BIT THE BOTTOM OF MY FOOT. I didn't think mosquitoes could bit there because it is thick rather than think skin. Well this tricky mosquito bit me right at the line where the skin turns from thin to thick skin (at the arch of my foot). I don't think I've ever experienced such horrible itching (probably because the foot has an incredibly high concentration of nerves). My usual tricks for alleviating the itching are not working (calamine lotion, diphenhydramine spray (Benadryl spray) and drying it out with rubbing alcohol). I've had to resort to icing it (except I don't have any ice so I'm "cold water bottle-ing it"). One of our professors said that part of the reason some people get so much more itchy than others is because some people have a hypersensitivity reaction (allergic reaction). I'm a text book example. I am itchy for about one hour after the bite then 24-48 hours I have the delayed reaction (itchy again) for another day or so. The cold is working and I think it is because it causes the blood vessels to vasoconstrict (contract) so less blood is getting to area of itching and thus my army overactive immune system cells and mediators are also not getting to the area of itchiness!

I keep telling myself that this stupid itching is due to end any moment (I should be nearing the end of the delayed reaction to the allergen), but then again, I didn't think mosquitoes could bit the bottom of your foot!

He's breathing...

During lunch, the Introducing to Clinical Medicine support staff were helping our professor (we'll call him Dr. Interesting because he NEVER gives a boring lecture) set up STAN. STAN is a relatively new took in medical training--1996. STAN is a simulator that breathes/respires, blinks, and I think he can even talk. He codes but since he is only a simulator, if a medical student make an error and gives the wrong medication, no one really dies. Yes, I said "gives the wrong medication". Students get to start IVs, give injections, perform CPR and even perform endotracheal intubation. You may have seen him on t.v. as he makes appearances on Grey's Anatomy and other medical shows. I'm not sure if our professors can talk back to us as STAN which is what happened on Gray's Anatomy, but I think they probably can. I do not know when students at United States Medical Schools get to start using the STAN machines, but I think it generally is later in their career (but this may have changed as there are more places with STANS). I have heard 3-4th years or even during residency, but I'm not sure and I couldn't find anything online. I do my first session (with 6 other students) next Thursday, so I'll report on if we can keep STAN alive or not.

Dr. Interesting's lecture was on respiratory failure. Because he is Dr. Interesting, he didn't just want to show pictures or videos of a patient, which is why he brought in STAN. Dr. Interesting showed us each method of increasing oxygen (such as a nasal cannulus, incubating and bagging the patient and putting a patient on a respirator). STAN's vital signs were on monitors all over the room (by monitors, I really mean large plasma t.v.s and a HUGE screen in the front. The huge screen isn't a projector, but it isn't a plasma t.v. either...it is probably 15 feet by 15 feet, which is also roughly the size t.v. that Farley wants in his bedroom). So Dr. Interesting kept things interesting by letting a student give the medicines to sedate and paralyze STAN and then Dr. Interesting incubated STAN. Let's just say, it was more fun than looking at a picture in a book. STAN got sleepy, closed his eyes, and once Dr. Interesting had incubated him, we could see the change s in STAN's breathing. Yes, Dr. Interesting got his nickname for a reason. Class was so much fun today.

Photo taken from an interesting article on simulators in medical training from The Guardian.

Doctors Orders: Two cups of coffee in the morning

Today we were discussing drugs used to treat respiratory disorders, such as asthma and chronic obstructive pulmonary disease (COPD). One class of older drugs methylxanthines, which includes the Theophylline, Aminoophylline and Caffeine, isn't used frequently and are not drugs of choice--nonetheless, we need to review them. These drugs work by inhibiting phosphodiesterase enzymes and blockade of adenosine receptors. Basically this means that they cause bronchodilation (but not as well as beta-2 agonists, such as abulterol), they increase the ventilatory response, increase mucociliary clearance (which is important in asthmatics because the pathology of asthma results in an increase in mucus), and improved diaphragmatic performance, which is unique to this class of drugs. Bottom line, these drugs makes it easier to breathe. I'm sure your wondering why I'm telling you all of this as you probably don't care about mechanisms of action and classes of drugs--if you did care you would be a pharmacists or a physician--I have a story about coffee.

Our lecturer today started teaching medical students in 1956 and is an MD and a PhD. I think he might be the smartest person I've ever met. He is an excellent professor and I think he could teach just about any topic in medicine school at any moment without much preparation. He is amazing in that he is so intelligent, never embarasses students, is extremely helpful and very modest (but he writes extremely difficult exam questions). After discussing the respiratory effects of Methylxanthines, we discussed effects in other systems such as the gastrointestinal tract, genital urinary tract, cardiac system and central nervous system. Obviously caffeine acts on the CNS, which is the point of this blog post. He made a point that moderate doses of caffeine has the following effects on the central nervous system:

• Cortical arousal with increased alertness and deferral of fatigue


• Decreased reaction time, more rapid and clear flow of though, and increased learning capability for simple tasks

Then he bluntly said in a thick Italian accent, "If you need to stay awake to study for your exams, please just have two cups of coffee. It will work better because you will be more alert and is safer than abusing other drugs." Through out the world, people abuse substances, such as Adderall which is an amphetamine, to keep them awake for school or work. I, personally, don't know of anyone who is abusing drugs to stay awake and study, but I do know that it is habitually done in medical schools and I'm sure some of my peers are doing so. It surprised me that he stopped to talk about drug abuse and reasons it is so horrible. Not only is he an amazing professor, I think he truly cares about his students (and he looks like a cute Italian grandpa). Now back to caffeine, there are obviously side effects if you take too high a dose of caffeine including insomnia, headache tremors, and headache (which he also warned us about). Nonetheless, the moral of the story is if you need help staying alert, Doctor's orders: two cups of coffee.

Without struggle, there is no reward

"Nothing in the world is worth having or worth doing unless it means effort, pain, difficulty... I have never in my life envied a human being who led an easy life. I have envied a great many people who led difficult lives and led them well." -- Theodore Roosevelt

I'm not claiming that my life has been difficult, for there are many people who have lived far more difficult lives than I; but, I am willing to claim that medical school is just the start of the difficulties that I face. I don't think I chose medicine, I think it chose me--I can't imagine my life in any other way. However, I didn't think I'd get to my end goal via an International Medical School. Nonetheless, I glad that I came down here. I knew becoming a physician meant that I would miss out on parts of my personal life and it would also mean that I would be an integral part of a relative strangers' personal lives in both the best of worst of times. It is just part of the package. Since coming to medical school, I haven't been too involved in stranger's lives yet (although I was in my position as clinical researcher). But I have already started to miss out on parts of my own life. Since starting school, I missed my grandmother's death and funeral, my cousin's wedding in the Puget Sound, multiple family BBQs, extended family trips to the Seattle area, birthdays, holidays, and tonight I'm missing my half-sister's wedding. I don't think it is any particular event that I'm sad about missing, but I do feel a bit like an outsider since I'm so far away. It might sound a bit selfish but in the end, I don't regret missing these events. In just a couple years, I will have the high honor of being a physician--even if I'm a little lonely and homesick from time to time. Nothing worth doing, comes without struggle.

This one is for you, Farley!

Farley and I have been debating the wonder that was Aretha Franklin's hat during the inauguration. I wasn't a huge fan, but Farley was. He has been offering to buy a hat just like it for me. With a little computer magic, I think I've proven my case that I'd look pretty stupid in a giant grey with rhinestones. Leave me a comment and let me know what you think of my picture in the ravishing hat.


Yesterday was such an amazing day. I know that people in my age group haven't historically been engaged in the political process; thus, it was so exciting to see my peers excited and participating in the process this year. (I haven't missed an election since turning 18, even while in Dominica!) When I was home, my favorite 5-year-old even asked who I voted for and what I thought of the election. Can you believe that a 5-year-old brought up politics?! She told me that she was so excited that Barack Obama was going to be the president and that she voted for him. I'm not sure if there was a mock election in her kindergarten class or grade school or if Mr. Obama is just who she would have voted for if she could vote. She even told me why she didn't like McCain, but that she knew others who voted for him and that is is okay to vote for different people. I suspect she was just telling me what she overheard her parents discussing or from the news, but she was pretty spot on.


I'm glad that yesterday happened to be a free study day for me. I put my TV on mute and when the exciting things were on TV, I took a study break to watch history. I even heard a European woman interviewed, who was in D.C., that said she wished she was an American because nothing like this could happen anywhere else in the world. I agree. It was a shining moment for our country and I was so proud to be an American yesterday.


I sure wouldn't want to take on being the Commander In Chief at this point in history, with the countless problems we face. However, I'm very glad that someone as intelligent, well-spoken, and level-headed is willing to take on these challenges that appear to have no end. Here is one of my favorite political cartoons from Slate Magazine:

I'm so ready to come home

I've been back in Dominica for a week and honestly, I'm shocked I've made it though the year on the island with such a positive attitude. Besides the brown water, the power outages, the expensive flights, the cold showers, the limited food choices on the island and the horrible misquotes, Dominica is the loudest place I have ever lived. There is a club OVER a mile away from my apartment. When I first arrived in Dominica, I could faintly hear the music of the club but in the past year it has gotten louder and louder. I am so tired. At least 2-3 days per week, there is music so loud that I can hear the lyrics with my windows closed, air conditioner on and ear plugs in until 2 or 3 in the morning. It was so bad that I got less than four hours of sleep per night the last week of last semester--the week that we had tests 50% of our grade in EVERY class within 48 hours. I emailed the school today and this was part of the response: " There are many laws in Dominica; unfortunately most of them are not regularly enforced. [The Club] is an integral part of the local community and attempts in the past to broach this subject have been unsuccessful." Seriously, I doubt activities at this club, which keep the rest of us awake several nights a week are an "integral part of the local community". I just don't buy it. The majority of the Dominicans I have met are family oriented, active in their Church, hard working (maybe slow but hard working) and up very early in the morning. I understand that the Caribbean cultures like to dance and jump up, but I don't think that they are all out doing it at least twice a week. During their multiple holidays, absolutely--I'm sure the majority of Dominicans are out at the party and "jumping up" but NOT every WEDNESDAY night. Dominicans do have jobs--generally working somehow with the school or students as there isn't much of economy besides the school! It isn't too much for them to just turn down the music a bit, as to not keep everyone else on the island awake. Besides, Dominica has more people per capital over the age of 100 in the world; I suspect they don't want to be up at 3:00am either! My flight back to Miami is Sunday, April 26, 2009 at 2:55 pm. Let the countdown begin!

Yes, You DO have the right book!

Yesterday, Farley and I bought the review book of all review books: "Rapid Interpretation of EKGs" by Dr. Dublin. The book just cracks me up. The back of the book doesn't describe how the book is set up just why is it such a great book. It talks about the imitators and how other review books have replaced "EKG" with "ECG" etc. I was laughing when I read the back of the book. The first point that made me laugh, "Yes! You do have the right book." and later when it says (highlighted in yellow) "There are books you buy for a course...This is a reference you keep for life." Please note, I had a hard time taking pictures for you to see this great reference, so I apologize that they are not my best pictures.



Obviously, I had to rip off the plastic and read this book immediately. I was not disappointed. For example, the yellow box under the Table of Contents: "Since this book will be your lifetime reference, you should place an identifying tab on the first page of each chapter." Then it highlights which pages start the chapter in the table of contents.


Finally, I started reading the first chapter. This books is beautiful. Every page is glossy, colored and the pages are thick, but not quite card stock. Each page starts with a drawing, graph or table. Readers are to first read the caption then try to understand the content of the drawing, graph or table. Next, it has a few sentences about the drawing, graph or table and expanding on the topic at hand. These sentences, however, lack a key word which is in the margin and you are expected to fill it in as you read (and obviously you can check if you are not sure). For example, it might say, "Living in Dominica, Nicole has many sunny days but also many ____ days because Dominica is not only near the equator but also a rain forest." Now in the margin it would say "rainy." It was actually fun to read the book. Luckily for me, there was yet another comment after the first page of chapter one, which made me chuckle: "*Get yourself a warm cup of coffee, relax and enjoy...the rest of the book is just as easy and entertaining."

I've never seen such a cocky text book, but if all the things I've read about it are true I guess it can afford to be cocky. From what I've seen so far, it is fun and easy--I just hope it stays that way. It has been published for over 30 years, is in it's 6th edition and the 60th publication...seems like reason to be cocky.

Start of the semester

I'm a bit surprised that I'm excited to be in class this morning--the semester break just didn't seem long enough. Both pharmacology and microbiology/immunology are worth 3 credits each this semester, pathology is worth 4 credits and Introduction to Clinical Medicine is worth 5 credits. This most exciting part of this semester is that we are starting to get more heavy on clinical medicine rather than just the books. We will be doing hospital days more frequently than last semester, which is both good and bad. It is good because I want to be a doctor (in large part) to work with people not just to think about theory in a philosophical manner. It is bad though, because the drive to the hospital is an hour and the road climbs uphill and downhill as well as bending tighter than a hair pen. YUCK! Thank goodness for Dramamine (dimenhydrinate) because without it, I'd be sick enough to be a patient by the time I get to the hospital. With the two hours of driving and the eight hours of clinic time, we will have fewer hours to study (which is always a bad thing). We will also be required to write multiple history and physicals, which is a great thing for me because writing up patient histories is probably one of my strongest skills as a medical student. You might be surprised that writing a history and physical is extremely important and not nearly as easy as it sounds it would be.

One funny thing was said today in class. We were told that if we are too sick to attend a clinic that we must call in (obviously, you have to call in when you have a job so it makes sense you have to call in as a student). The funny thing was that our professor said, "if you are too sick to be in clinic [as a student] than we will send a transfer to pick you up so we can see you [as a patient] to check you out." That is one great thing about medical school: there are plenty of people to make sure we are healthy and wise!

Davenport, Clinks and a long flight back to school.

Last Sunday, Mom and Dad planned a great surprise before I left: a trip down to the Davenport for the Sunday Brunch. Yummy! It is one of my favorite things in Spokane, but it is so expensive, it isn't a treat you can enjoy too much! A few family members even agreed to come down too, so not only was the food great, the company was the best a gal could ask for.

After enjoying the Davenport, we went down to River Park Square and picked up a few last minute things. They still had up the tree, so it it is:


On Monday, I had a few million errands to run. Luckily, Mom and Dad were with me, so it wasn't so bad. We even had time to stop for a nice lunch at the Mustard Seed. Tuesday, got to spend part of my afternoon at Sacred Heart Children's Hospital seeing some of the doctors that inspired me to move a world away to train so that I one day can also be an inspiring physician. It was so nice to talk to people who know exactly what it feels like to be so overwhelming tired and extremely stressed. One of the best parts of the day was seeing a little one that was on studies while I was a clinical researcher. He was less than a year when he was diagnosed and after his bone marrow transplant, I helped him walk down the hall. Now, he must be three or four and if I hadn't seen him as a baby and known he had leukemia, I never would have guessed it by looking at him now. It makes me excited to become a physician--to make a real difference in people's lives.


On Thursday night, Mom, Dad and I went to clinks for my last dinner at home. It was so great! Here are some pictures:

Leaving on Friday was much harder than I thought it would be. I thought after being gone for so long that I wouldn't have as hard of a time saying goodbye, but I think it was worse than last year. After leaving Spokane, I flew to Seattle and had about a 15 minute layover before boarding for what I thought was a direct flight to Fort Lauderdale, but instead we stopped quickly in Nashville. Finally, I arrived in Fort Lauderdale! Farley and his uncle picked me up and then we went down to Miami and saw Farley's paternal grandparents. We left for Barbados Saturday morning at 10:00 and arrived in Barbados at 3:00 local time. The Barbadian airport is probably the jewel of the Caribbean airports: there were shops, and restaurants and even a quick moving customs. Amazing!

The closest hotel to the airport, was a beautiful little gem on the beach. The hotel had great architecture and the beach was one of the most breath-taking that I've seen. It was a very windy location and there were tons of wind surfers and kite surfers. Farley and I had enough time to take a stroll on the beach and read novels on beach chairs near the pool and overlooking the sea. We had dinner on a deck that overlooks the sea. It was a full moon and the sea was so beautiful as the waves were dancing in the moonlight.

Below: my messy hair on the windy, beach.


Below: Look at all the wind and kite surfers!