All In A Day's Work

108F.  That was the real-feel temperature this afternoon in Iowa City!  When I walked out of the highly air conditioned lab, I felt as if I had walked into a solid wall of heat.  My sunglasses steamed up and my hands felt clammy due to the sudden increase in humidity.  But when I complained about the heat, native Iowans told me, “just wait until the end of July, it gets worse!”  Luckily, I won’t have to find out, as the last day of my internship here is July 16th.

It took me awhile to decide what to write about in this post because for the last few weeks I have been doing more or less the same things in lab, but then I thought of something I haven’t told you guys about yet.  C-sections!  So far I have been to three C-sections and in doing so I have witnessed the birth of four babies.  These have been some of my favorite experiences of the summer so far.

Throughout rounds in the NICU it is not uncommon for one of the residents’ pagers to go off; usually it is another department calling to answer a consult or to ask a question.  Sometimes, though, all four pagers go off loudly at once.  In my experience, this means one thing: more hands are needed in the operating room!  Usually two residents and a nurse respond to the call, and since I’ve started wearing scrubs in place of professional clothes, I’m allowed to tag along!  The whole thing is very efficient because the OR is directly next door to the NICU.

We hurry down the hall to a big cabinet where we dress for the operating room: blue shoe covers, yellow long-sleeve smock, gloves, mask, and hair-covering.  By the time we are all suited up, our eyes and ears are the only skin showing and it’s nearly impossible to tell us apart (this makes me feel better going into the OR, because at least I look like I know what I’m doing).  Then we head through a pair of huge double doors.  By the time we arrive, the surgeons are already well on their way to opening the uterus.  In subsequent conversations with my housemates, I’ve learned that C-sections are well known to be some of the “goriest” surgeries simply due to the volume of blood and fluid that is involved.  I didn’t know this my first time observing though, and I was glad my mask covered me as I stared open mouthed at the outpouring of blood.  When the surgeons finally punctured the amniotic sac, my first thought was of a volcano; suddenly I understood why the surgeons had plastic shields covering their faces from mouth to forehead.

Once the incision is made, the surgeons pull the baby out - a task which turns out to be very laborious.  They pull and push and strain until finally the infant slips out and is handed immediately to the baby team (in this case, the NICU residents).  It is the baby team’s job to rub and suction the baby until it cries, then clean and swaddle it.  One of the babies I saw delivered weighed over 10 lbs!  She looked HUGE compared to the tiny infants I’m used to seeing in the NICU.  The delivering surgeon was petite, and clearly had to struggle to pull the baby out.  As another surgeon, observing next to me, said into my ear, “poor thing, that baby is bigger than she is!”

During each baby’s first few minutes of life, I like to watch the family members who are present in the operating room; sometimes the father has come, other times it is a sister or grandmother.  But without fail, they all tear up and watch in joyous disbelief as the newest member of their family turns pink and wails.  It reminds me of how wonderful life is, and of all the amazing potential ahead of every newborn.  Meanwhile, the baby team takes the new baby to “Transition” where it will prepare to go home, and heads back to finish rounds in the NICU.  They treat the whole thing as if it is a perfectly normal occurrence.  It’s not quite normal to me yet though, and I count myself lucky to work with people for whom bringing  new life into this world is all in a day’s work.

Data!

The McElroy lab is growing! In the past two weeks, two new research assistants have started working here: Huiyu, who has many years of lab experience, and Mitch, who is a recent college graduate. With double the number of hands, our projects are quickly getting underway. Huiyu’s experience is a great resource for Matt, Mitch, and I; she is teaching us a lot!

Earlier this week I finished the first two sets of slides for villus measurements. We ran some statistics on the numbers, and for mice both 21- and 28-days-old there was a significant difference between the villus lengths of treated vs untreated mice. This is good news; thus far, our hypothesis is holding water. Even more exciting, I won the race to produce the first piece of data from our lab on the three projects we started this summer! Victory! I have four more villi slide sets to finish measuring and my ongoing RT-PCR work looking at changes in the intestinal stem cells, so I am keeping busy.

Happy Solstice, everyone! :)

All About Med School

While brushing my teeth this morning I glanced out at the house parking lot and was amused by how similar all the cars were.  Parked behind Phi Rho are four Camrys, two Impalas, three Accords, two Civics, and one lonely Ford Edge crossover.  I have entered the world of the mid- to late- twenty-somethings - the land of the young professionals.  Two of my closest friends here are 26 and 29 (to my 20); everyone in the house is at least three years older than I am.  For the most part, the age gap is barely noticeable and I usually forget about it, but from time to time differences between this crowd and that of the undergrads jump out at me.  Some of these differences are humorous – it seems like someone runs off to a wedding almost every other day – while others are more unnerving.  For example, the med students mention debt quite a bit.  A few days ago my friend Katy (talking about undergraduate loans) said nonchalantly, “well I was able to pay off about $10,000 dollars last year, and if I keep budgeting well I hope to pay off another $8,000 this year and then I will only have $4,000 to go!”  Yikes!  However, my housemates have instructed me that I am not allowed to start worrying about debt until at least after I’ve graduated from Juniata.  So I’m ok for now.

One of the perks of living in a house full of medical students is getting an inside look at med school.  Again, there are unsettling aspects; for example, most of the second years are all but invisible because they have shut themselves away in order to finish the months long process of studying for the Boards, a cumulative exam that weighs heavily on the residency position they will receive (again, I have been told I am not allowed to worry about this yet).  But it’s also very cool to hear them sit around and discuss cases they encounter during rotations or situations from recent classes.  I have gotten to hear about many of the fun traditions at Iowa’s med school and learn about their future aspirations, and it is all extremely interesting.  Yesterday I got very excited about the idea of med school because an MD/PhD student told me about the various classes he has taken here.  His favorite course was anatomy lab because, “when you pick up the scalpel and prepare to make your first cut, it hits you that you are being trusted with the opportunity to do something that most people in the world are prohibited from doing.  The power and responsibility of the position you are training for really hits you in that moment!”  It is clear the med students are all very passionate about learning, science, and medicine.  I cannot wait to join their ranks!  

It has also been very informative to discuss with my housemates why they chose to come to Iowa over other med schools.  In talking with them I am learning what to look for and what questions to ask when I begin my search.  Many of the current med students did not come here directly after undergrad, but took time to do things like serve in the military, conduct research, or join the Peace Corps; since I am planning on taking a gap year between undergrad and med school, it is reassuring to know that I will not be out of the ordinary.  With the gap year I still have three years until I start medical school, but I am already looking forward to it!

Lab Update

Working in a lab can be summed up in one word: patience (no, not patients; that's working in the hospital).  Most of the time is spent planning and preparing for the crucial data-producing step of an experiment.  Of course, this crucial step (which involves a lot of waiting while the experiment runs) usually does not work the way you thought it would, so it's back to planning again.  The hope is that eventually you find the right parameters and conditions, produce good data, and maybe even learn something new!

My project, which should have started around the beginning of the month, had to be pushed back because the company we order the supplies from lost our order.  We reordered and the materials got here on Monday!  So I am moving forward.  However, last week while I was waiting I got to become very good friends with this guy:

This is our new Nikon microscope!  It can do both bright field and fluorescence imaging, and it is very, very nice.  I've been using it to measure the lengths of intestinal villi (the little fingers that stick out into the intestine to absorb nutrients) on slides from mice that Dr. McElroy used in past experiments.  The goal is that I measure about 100 villi per slide on 50 or more slides, so I have been seeing A LOT of this:

We are comparing villi lengths between mice treated with two different substances.  It is not very interesting, but it needs to be done.  But now that my materials are here I can put villi measuring on hold and start looking at variation in stem cell gene expression in mice that we induced to develop NEC!

  

Here I am in the process of extracting RNA

Tomorrow is a big day in lab because we are going to induce NEC in 10 mice pups, and then after several hours we will harvest the small intestine and preserve it.  We use the tissue to make slides and extract protein and RNA for our various experiments.

Matt prepares small intestine samples

 This is our -80 C freezer where we store tissue samples, RNA, cDNA, etc.  Every time I open it I feel like I am opening some kind of crazy time machine because so much steam billows out!

It Takes A Village

Once a week Matt and I put on our dress shoes and make our way up to the 7th floor of the hospital to observe rounds in the Neonatal Intensive Care Unit. The NICU has 65 beds, and is divided into 4 “bays.” We shadow in Bay 1, the 12-bed unit for the infants needing the most intensive care. These babies would not survive without the respirators, antibiotics, surgeries, nutrients, labs, and care we provide for them. They are lucky to be born here because the University of Iowa’s NICU has one of the highest patient survival rates in the country!

For the most part, rounds are straightforward. A herd of about 12 of us (the attending physician, fellows, residents, a dietary specialist, nurses, pharmacy students, respiratory specialists, Matt and me) moves along the U-shaped hall stopping at each room to discuss how each patient did overnight, and their plan for the next few days. The NICU truly is the saying, ‘it takes a village to raise a child,’ put into action. Depending on how crazy the night was, rounds can last anywhere from 1 to 4 hours – let me tell you, it’s a long time to stand! Still, no matter how tired my legs get, I always feel better off than the residents, who usually look pretty tired. They work 12-hour days for 2- or 3-week blocks of time and are in charge of most of the direct patient care and planning. They are impressive!

The discussions about the patients are overflowing with acronyms and jargon that I am unfamiliar with. I have no frame of reference for what changing the feeding volume from 8Q6 to 9Q4 means, what a ventilator PIP setting of 20/7 signifies, or the implications of the number of ribs you can count on a chest x-ray. So what sticks with me from my days in the NICU aren’t the specifics of the infants’ care; what I remember are the impressions and small details: the look of trust in a mother’s eyes as the doctor tells her, “your daughter is in good hands, we will take care of her;” or how unbelievably small a baby can be. Many weigh less than 1.5 lbs at birth and are about 7 inches long (their diapers are made by Pampers, but look like they are for dolls).

There is a continuous low whirring of machines in the NICU. Every patient I’ve seen has been on a respirator and the noise quickly fades into the background. I didn’t realize how accustomed I had become to the sound until a patient only a few hours old was airlifted to our NICU last Friday. He was tiny, pink and cute, squirming and whimpering as the nurses hooked him up to the many monitors. But something was off, and it took me a while to place it. I finally realized it was his crying. None of the infants in the NICU ever make any noise; they can’t because their ventilators control their breathing. Soon one of the residents was intubating the new baby. It made me sad to see his tiny body put into such an awkward and unnatural position - his little chest thrust upward and his head tilted way back as she thrust the tube down his throat. I hated seeing him look so sick and helpless; how could he possibly get better, especially when we were jamming things into him left and right?

During moments like these I try to remember something Dr. Segar, head of the NICU, told a mother on my first day shadowing. Her daughter was 4 days old. Overwhelmed by the implications of what the doctors were saying, she had burst into tears. Dr. Segar put a hand on her arm and said, “Everything we do is going to hurt them, we just try to hurt them as little as possible and one day their body will be able to repair faster than we do damage - that’s when they finally take a turn for the better. Until then they are going to have good days and terrible days, but that’s why we’re here.”