Human Anatomy at Colby

Rachel Bird: Flipped Classroom

February 24th, 2015 · Comments Off on Rachel Bird: Flipped Classroom

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When I showed up to the first day of my Introduction to Human Anatomy and Physiology JanPlan class, the professor, Dr. Klepach, told us that, for the first week (and maybe longer), we wouldn’t be having a typical lecture-style class. Instead, we were expected to watch podcasts of the following day’s lesson and come up with questions to go over with our classmates. Then, during the lecture block, we would be doing activities and having discussions about the material we had reviewed the night before. After lecture, we would go to the lab for 90 minutes to review anatomical structures and study histological slides in preparation for our lab practicals. As a student athlete with two jobs on campus, having an additional hour and a half of podcasts to watch outside of class, in addition to the homework and studying that was already expected of me, was pretty overwhelming. An average day for me started at 5:45am, when I woke up for morning practice, and then I was either at work, class, practice, or reviewing for the next day’s lecture until I crashed in my bed at night. However, as taxing as the first week of JanPlan was for me, the flipped classroom experiment definitely did pay off in some ways.

For one, it allowed my classmates and me to do fun, interactive activities during lecture block, instead of just sitting listening to a professor talk. One day, during a lecture block devoted to neuron firing and cell physiology, we split into groups and acted out the different types of graded and action potentials. Understanding the electrochemical gradient was a lot easier when I could see my classmates passing through a doorway to achieve an even number of students on each side!

Another benefit to the flipped classroom is that I went into class each day feeling far more prepared and ready to learn. In a fast-paced, content-heavy course like Anatomy and Physiology, it definitely helped me to be able to come to lecture already prepared with questions from the lecture. Given that we were trying to fit a full-length college anatomy class into only three and a half weeks of JanPlan, it was really important to be prepared for class and stay on top of the material. The recorded lectures were helpful in this way because if I missed something while taking notes or needed more review on a topic, I could just pause of rewind the video to the section I wanted to watch again. However, the fact that the lectures were recorded meant that I couldn’t raise my hand to ask the professor a question when it occurred to me, and I would need to wait until the next day for clarification, usually when the topic was no longer fresh in my mind.

As interesting as the flipped classroom experiment was, I was glad when the class voted to return to a normal lecture style for the remaining weeks of JanPlan. Not only did a standard lecture structure allow me more time for athletics and my job, I also felt less stressed about trying to find a 90 minute or longer block of time where I could watch the lectures. Luckily, the PDFs of the lecture slides, and all of the podcasts, were still available through the class website, so if I missed something in class I was able to go back after and review. Although I think that a flipped classroom would probably work better during the regular semester, as opposed to JanPlan, which is already hectic, it was definitely an interesting experiment that forced me to work on budgeting my time and planning out my day so that I could fit in all my commitments.

Tags: Bi265j

Rachel Bird: The End of My Gymnastics Career

February 23rd, 2015 · Comments Off on Rachel Bird: The End of My Gymnastics Career

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I used to be squeamish. I was the kid who’d cover their face during movie fight scenes and feel nauseous at the sight of a bloody hangnail. Then I hurt myself — badly — during gymnastics practice, and I realized that as queasy my innards made me, it was worth it to understand them. When I fell on the trampoline during a routine in April 2012, I shattered my left radius and ulna. The repeated bouncing after the initial fall damaged the soft tissue and left the bones in a compound fracture, puncturing my skin halfway up the forearm. Although the initial reconstructive surgeries were able to salvage some of the bone and repair the structure of my arm, the massive soft tissue damage made my arm swell under the surgical dressings. My fingers grew so puffy with edema that they pressed together, despite the dressing that kept them spread as wide as physically possible. My elbow swelled to the size of my knee, and the staples holding the skin on the inner side of my forearm split open and the wound started oozing.

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Eventually, the doctors diagnosed me with compartment syndrome, a condition that is common in crush injuries, but not frequently found in the type of break I had. Because of all the damage to the muscle tissue, my arm had swelled so much that the blood vessels were squeezed almost shut, preventing oxygen from getting to the nerves and muscles in my hand. Unfortunately, by the time I was diagnosed with compartment syndrome, the damage had already been done. The typical treatment for compartment syndrome is a WoundVac, which is essentially a vacuum that attaches onto an opening in the dermis and sucks out all the excess fluid before it can cause a problem. However, by the time the nurses had removed my surgical wraps and determined the cause of the swelling and burning sensation in my arm, the swelling had already begun to subside. Initially, the doctors believed that the nerves would be able to regrow, and most of the damage could heal on its own. However, after two months of daily occupational and physical therapy, I still had no sensation in my wrist, palm, or fingers. Even worse, the build-up scar tissue had cemented my fingers into a fist, and I only had roughly 15 degrees of mobility in my elbow and even fewer in my wrist. My hand was so stuck that I was unable to open my hand to trim my fingernails, so they were starting to grow into the skin on my palm. I didn’t even notice until it started bleeding, because I had no functioning pain nerves in my hand. I also had no proprioception, so when I wasn’t looking at my hand, I would have no idea where it was. This led to some funny encounters, because I would all-to-frequently end up with my hand in my food, or touching a stranger’ back!

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After visits to numerous specialists, Dr. Barth, an orthopedic surgeon who specialized in hand and foot injuries suggested an unusual fix. He planned to surgically open up my forearm and scrape the scar tissue off of the joints and tendons in my hand. He would also remove the dead muscle tissue, but leave the muscle bellies (the central portion of a muscle), in the hope that the few remaining muscle fibers would be able to grow. Hopefully, without all the scar tissue blocking blood flow, some of the nerves in my arm would be able to grow back.

Luckily, the surgery was mostly successful, and I was able to open my hand. Less than two weeks after I was discharged from the hospital, I was able to feel deep pressure in my wrist and in parts of my palm! Nerves regrow at approximately five millimeters per day for larger nerves, so as my median nerve inched up my palm, my occupational therapist could track its growth with touch charts and a photocopy of an anatomy textbook. However, so much muscle and tendon was removed, that even though I was slowly able to feel the proximal areas of my fingers, I didn’t have the strength to move them. My arm was so weak that I had to wear a sling for most of the day because I couldn’t support my hand. Even worse, because I couldn’t feel scratches or cuts, two small paper cuts on my fingers got infected.

Dr. Barth proposed another surgery. He wanted to transfer a tendon from my upper arm into my forearm, in the hopes that I could “retrain” my brain to use one tendon for a different purpose. The surgery transferred the brachioradialis tendon and attached it to my extensor pollicis brevis, so when I wanted to move the distal joint of my thumb, I would have to think about bending my elbow. He also transferred the flexor carpi radialis and attached it to the flexor digitorum superficialis, so when I wanted curl or flex my fingers, I would use the muscle that had previously bent my wrist.

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Although the process of recovering from this surgery and relearning how to use my hand to nearly two years, I am now able to type this paper using both hands (admittedly, it’s kind of awkward)! Unfortunately, having blood flow cut off to my nerves for so long had left me with permanent nerve damage, and I deal with chronic nerve pain and pretty limited strength and mobility. However, I can tie my shoes, dress myself and function in a classroom setting in ways that I couldn’t have dreamed of in the months following my accident, and I am so thankful to modern medicine for that!

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Tags: Human Health · Personal Story

Rachel Bird: My Concussion

February 23rd, 2015 · Comments Off on Rachel Bird: My Concussion

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Let me preface this by saying that I do not know how to ski. However, I’m a decent snowboarder, and I (mistakenly) thought that the two skills were relatively similar. Apparently I’m quite incorrect. The result is that this entire blog post is hearsay. I have absolutely no memory from Saturday, January 17 until Monday, January 19. According to my friends, on Sunday morning, we all got up early to drive up to Sugarloaf mountain to enjoy Colby Ski Weekend, with discounted lift tickets. The morning skiing was decent, but crowded. I was slowly (but surely) figuring out how to ski, and when we stopped for lunch I was feeling pretty confident. After a few successful runs in the afternoon, it was starting to rain, and the slopes had become slick and icy. We decided to do one last run and then head home. Our group got split up on one of the turns, and I ended up going ahead. When I hit a particularly icy patch, my right ski slipped out from under me and I rolled down a hill. I ended up at a fork in the trail and I went right, following a skier in black who I assumed was my friend. At the next fork in the trail, the only options were two different black diamonds, and the woman I had been following was clearly not a fellow novice skier! I reluctantly chose the path to the right and crossed my fingers. Initially, I was doing fine, slaloming side to side and avoiding the smooth icy patches in the center. Then I came on a steep slope and started to lose control. I tried to slow down, but the rain and melting ice didn’t offer any traction for my rental skis. I careened off the trail and down a hill into the woods, banging my skin on a branch and knocking the base of my head against a tree stump. I blacked out.

I woke to an old man in a green jacket poking me with his ski pole, “Are you okay, sweetheart?”

“Yeah, I’m fine, just give me a second.”

I crawled out of the woods and adjusted my goggles on my too-big rental helmet. I clamped my skis back on and gingerly slid the rest of the way down the mountain to the lodge. I mechanically returned my skis, boots, and helmet, and returned to our picnic table to change into dry clothes. I felt fine — a little drained, but that’s understandable after a long day at the mountain. As we waited for the shuttle to take us back to the parking lot, sleet and rain pelted down. The shuttle finally showed up, but on the way to the parking lot, my head started to pound. I blinked the snow out of my eyes, but my vision stayed blurry.

“Hey Chris — I think I’m seeing double.”

My boyfriend’s face swam in front of me, his mouth splitting into two identical sets of lips and then merging back into one.

“Do you feel okay?” Michaela’s voice piped up from my periphery, her head smearing into an unidentifiable mass.

“Um… I don’t know. I think I hit my head pretty hard when I fell.”

“We’ll get you to the health center when we get back to campus.”

“Ok.”

The shuttle pulled up to the parking lot, and I slouched into the backseat of Tenzin’s car. The sleet kept pouring down as we inched down the steep road. I slumped over on Chris’ shoulder, but he kept shaking me awake.

“Rachel, I really don’t think you should go to sleep yet, you might have a concussion.”

Then the car swerved and Tenzon overcorrected and the wheels slid and the road curved and we were in a snow bank. My head whipped forward and hit the seat in front of me with a resounding thump. Tenzin and Katie climbed out the front doors to survey the damage. The car was fine, but we were clearly stuck in the snow on the side of the road. Luckily, an ambulance happened to be passing by and the EMTs pulled over to see how we were doing.

“We’re all fine, but our friend is in the back seat, and we think she’s got a concussion.”

I crawled out of the back window, and stumbled over the the ambulance. The EMTs chattered between themselves, and apparently reached some consensus, because I was loaded into the back of the ambulance and barraged with questions.

“What year is it? What’s your name? Who is the president? Where do you live? Do you know your address? Are you taking any medicines?”

“Um. I don’t remember… I’m really sorry. I don’t know… uh… I don’t remember.”

Everything was fuzzy as the EMTs started an IV, and I dry-heaved into a plastic bucket.

“Zofran for the nausea and fluids for dehydration.”

I slumped onto the stretcher and blinked in time with my head’s pounding. Somehow I made it to Farmington Hospital and into a hospital bed, but I was too busy focusing on the peculiar way my forehead was pulsing. More nurses with more questions that I couldn’t quite conjure the answers to, more bright lights and beeping noises that made my head pound, more medical terminology that I was sure I had heard before, but I couldn’t quite place. The tall doctor called for a CAT scan, but I needed to give a urine sample first to prove I wasn’t pregnant, and my head hurt too much to get up and use the bathroom. But I gave the sample, and got the scan, and went back into my hospital bed, and tried not to fall asleep with my eyes open, because I was so damn tired. Hours or maybe seconds passed and the tall doctor sauntered back into the room. My boyfriend jumped up and began badgering him with questions. I took the opportunity to promptly fall asleep while sitting up.

“No internal hemorrhaging, which is good, but she’s got a pretty severe concussion…”

The doctor’s voice trailed off into technicalities, but I was already fast asleep.

 

 

Tags: Human Health

Rachel Bird: Heart Dissection

February 22nd, 2015 · Comments Off on Rachel Bird: Heart Dissection

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I know, rationally, that the brightly colored red and blue heart diagrams in the spiral bound textbook on the lab table aren’t entirely accurate. However, I was surprised at how disappointed I was to open the box of shrink-wrapped pig hearts and discover that the entire heart is a homogenous beige color – somewhere in between tea with too much milk in it and the thick clay in the riverbeds near my house. Luckily, that disappointment didn’t last. As my lab partner, Rebecca, and I unsealed the plastic wrap, our first impression of the heart was the smell. Acidic, chemically, headache-inducing: the preservatives that kept our heart from smelling like rotting meat also made the entire lab smell like the inside of a formaldehyde bottle!

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As our noses adjusted, we began our cursory inspection of the heart. Once I was able to get over the bland coloration, our pig heart actually looked remarkably like the textbook model. From the shriveled atria to the rubbery arteries, our pig heart just looked like a small-scale reproduction of the plastic hearts that had been on display on the lab tables all week. Once we oriented the heart with the apex pointing down, Rebecca made the first cut, deftly slicing the heart in half like a bagel. We both gasped. The interior of the large, muscular ventricles was covered in delicate, stringy chordae tendineae! The textbook photos and models mentioned these fibrous bands, but the lightly sketched lines in our reference image in no way prepared us for the network of elastic filaments that criss-crossed through the ventricles. Rebecca tugged at one of the strands, but instead of breaking, it snapped back into place as soon as she released it. Those things are a lot stronger than they look!

Our second surprise was the septum’s thickness. We had both memorized the fact that the left ventricle has stronger muscle walls than the right ventricle (because while the right ventricle only pumps blood back into the lungs to get oxygenated, the left ventricle has to distribute blood to the entire body). However, the difference was huge! The septum was thick and muscular and not at all thin like the cartilaginous septum that separates the nostrils. As we continued to hack away… or rather, “dissect,” our heart, we noticed that if you pulled the filmy visceral pericardium away from the outer walls of the heart, it revealed rougher, almost striated muscle tissue below. It was even possible to pull up small strands of muscle tissue with the tweezers and separate the layers of the heart muscle. The same was true of the interior of the ventricles – once we peeled back the smooth endothelium that protected the inner walls of the heart, the coarser muscle tissue was revealed.

Even more interesting than the layers of the heart muscle was the layered structure of the veins and arteries splaying out of the heart. After Rebecca and I had thoroughly examined all the entrances and exits to the heart (mostly by sticking our fingers in the tubes to figure out which chamber each one led to), we sliced off a section of the aorta and attempted to identify the layers of the tissue that compose an artery.

By the time we were finished, our pig heart lay in chunks all over the dissecting tray. Rebecca was poking one end of her tweezers through the coronary artery and I was still stubbornly trying to “de-fat” the right atrium. As class time ran out, we reluctantly cleaned up our heart and threw out our gloves, eager to get the scent of preservatives off our hands. As Rebecca and I threw out the last of our paper towels, I turned to her and said, “I hope they aren’t serving pork carnitas again at lunch. I don’t really think I can imagine eating pork after that…”

 

 

Tags: Lab

Grand Rounds: Oligoastrocytoma

January 28th, 2015 · Comments Off on Grand Rounds: Oligoastrocytoma

Grand Rounds: Oligoastrocytoma

Alex Lucas, Yvette Qu, Rachel Bird

 

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Oligoastrocytoma

Oligoastrocytomas are brain tumors that consist of oligodendrocytes and astrocytes, the two cell types in the brain that support and insulate nerve cells. Unlike many brain tumors, which typically present initially with headaches, seizures are a common initial symptom of oligoastrocytomas.

The patient presented with episodes of “a feeling of walking through a cloud,” receptive, or Wernicke’s aphasia (the inability to understand spoken words), Aphasia (inability to speak), and vertigo. She also suffered from brief seizures, which worsened in severity over the course of the next eight years, and began to involve loss of consciousness and muscle tone, occasional incontinence, and overwhelming confusion. Three months prior to admittance, the patient struck her head during an episode, but MRI, ECG, echocardiography, Holter monitoring, EEG and multiple blood tests all appeared normal. The patient did not respond to triptans or beta-blockers, but the frequency of her seizures increased to at least one per day.

An MRI was performed on the patient, which showed a mass in the left occipitotemporal region of the brain. A biopsy helped to determine the grade of the tumor – grade II, which is a low grade tumor – and also presents the pathology which helps to determine the growth patterns of the tumor cells. Fluorescence in situ hybridization (FISH), which allows for reliable and accurate detection of chromosomal deletions, showed deletions in 1p and 19q tumors.

Similar to most tumors, the exact cause of an oligoastrocytoma is unknown. It is understood that normal cells become abnormal in the sense that they may produce the wrong number of proteins or enzymes or be lacking certain genetic material. In the case of an oligoastrocytoma, deletions of genetic information in chromosomes 1p and 19q are the reason for the tumor cell’s abnormalities. This certain type of tumor is a result of a mixture of oligodendrocytes and astrocytes. Genetic material losses in 19q occur in 60-80% of oligodendrogliomas and 30-40% in astrocytomas, which demonstrate that there may be a shared variation in the formation of gliomas. Losses in the 1p chromosome are frequent with oligodendrogliomas at about 50-80%, however are less apparent with astrocytomas, which is detected only 10-18% of the time. However, the combination of genetic material losses of the 1p and 19q chromosomes is detected in 60-80% of oligoastrocytoma cases.

A gross resection was performed to remove the patient’s low-grade oligoastrocytoma tumor. Standard radiotherapy and antiepileptic medications were given after the resection. Lifelong MRI was suggested instead of permanent pacemaker due to the low-grade of the tumor. Following MRI shows only postsurgical changes, implying good prognosis. During the 24-month following the resection, no seizure has occurred with reduction in medication, indicating great possibility of freedom from seizure in 10 years and absence of intractability.

The patient’s case is complicated by ictal asystole (stopping of the heart during her epileptic seizures, which is very rare) in a patient with a predisposition to neurocardiogenic syncope (fainting, loss of consciousness, loss of muscle tone due to an abnormal control mechanism of the brain over the heart) due to a genetic disorder, and with the asystole being triggered by the seizures caused by her oligoastrocytoma make this case very interesting and unique. The important information the case conveys is that a patient’s symptoms are not always indications of a single disease, and sometimes the symptoms need to be closely examined and can suggest more than one disease. Perhaps screening for relationships between cardiac dysfunction and neurologic mechanisms could help identify rare cases such as this one, which would allow for earlier diagnosis and treatment.

References:

(1) Paleologos, N A, ed. Oligodendroglioma and Oligoastrocytoma. Am Br Tum Assoc 2014: 3-8.

(2) Oligoastrocytoma. Univ CO Sch of Med Neusrgy 2015.

(3) Meenakshi G, MD, Azita Djalilvand, MD, Daniel J. Brat, MD, PhD. Clarifying the Diffuse Gliomas. Am J Clin Pathol. 2005;124(5):755-768.

(4) Cole, AJ, M.D., Eskandar, E. M.D., Mela, T, M.D., Noebels, J.L. M.D., Ph.D., Gonzalez, R.G. M.D., Ph.D., McGuone, D, M.B., Ch.B. Case 18-2013 — A 32-Year-Old Woman with Recurrent Episodes of Altered Consciousness. N Engl J Med 2013; 368:2304-2312.

(5) Ucdenver.edu. Department of Neurosurgery [Internet]. 2015 [cited 2015 Jan 15]; Available from:http://www.ucdenver.edu/academics/colleges/medicalschool/departments/Neurosurgery/patientcare/multi-disciplinaryprograms/AdultBrainTumorProgram/Pages/Oligoastrocytoma.aspx

 

 

Tags: Grand Rounds