Liquid Dreams

With each day’s worth of musings, I get a clearer picture of what I want to do with my life:  Anesthesia.  What I will be doing for people will be what I do best myself:  Sleep.  Like putting together my morning cup of coffee to keep me moving like the Energizer bunny, I will become a master of the sleeping cocktail:  ease in the midazolam (oh the beauty of benzos!), breathe in a whole lotta oxygen (you know you like O2 when you go swimming), pump in the milky propofol (works like a charm!), spice up with some fine fine fentanyl (very strong opioid), jazz up with a little lidocaine (local anesthetic), top off the opening act with a pinch of vecuronium (muscle relaxant), and add a continuous whiff of sevoflurane (inhaled anesthetic), and your patient is in another universe.  Now you have a fully sleeping patient probably cruising halfway to Hawaii already.

This past month and a half, I’ve been having long, constant pondering sessions on what I want to do for the next 30 plus years,  Emergency Medicine vs. Anesthesia.  Amidst my inner mental battles, I also have to figure out my 4th year schedule and away electives at prospective places I may wish to do residency.  But of course, both these plans hinder on me having a rock solid idea of what field I’m going into.  I run a daily list of pros and cons. I chat with residents and attending physicians day in and day out.  I consider lifestyle, because I need to eat/cook/sleep/watch dramas/read/exercise/vacation/yada yada … I also factor in the murky future for physicians and the general unknown world of health care we must accept, thanks to Obamacare.

Clearly, I’m in high stress mode these few months.  I have to make a career-changing decision, STAT.  In a couple of years time, I will have a job, albeit a five-digit figure, barely enough for life’s sustenance for the amount of work I’ll be scutting.

And you know what happens to me when my brain is on overdrive?  That’s right, I start having funky dreams.

Last night, I had a dream I was in the operating room.  I was on the anesthesia side, behind the curtains with the fancy monitors and gadgets, gases, and medications.  One of the crucial intraoperative tasks of an anesthesiologist is to monitor vital signs … and input/output.  Input is how much fluids (or blood) is going into the patient, while output is measured by how much urine is coming out (and blood loss).  Typically, patients under general anesthesia have a Foley catheter to the bladder, and urine is collected and measured.  In the case the container fills up, the urine gets emptied out.  Usually you do not expect much urine because patients going in for surgery are kept NPO (no food or drink at least 8 hours before the operation). Except in my wet dreams…

In my dreams, the patient on the table kept peeing out the Foley catheter, and I was mysteriously knighted the responsibility of emptying the containers under the table.  So much pee was flowing through the tube and container that I just could not keep up!  I was panicking, blubbering and shaking.  There were jugs and coolers filled with pee!!!  I was on my hands and knees under the sterile drapes trying to maintain pee control!  Where was the anesthesia resident to help me?!  Was the surgeon above the table yelling at how inept I was?  I heard nothing:  no surgeon cursing, no anesthesia to the rescue… Oddly enough, there was also no spillage and flooding onto the floor, or splashes to my face o.O   It was like the calm of a storm, the eye of a hurricane.  I turned back to the container in front of me, pushed down on the release button (like those spigots on the giant jugs you see for football games), and collected the continuously flowing pee…

And then I woke up before I could remotely make sense of this bizarre setting.

What a baffling dream?!  There was just a free-flowing fountain of pee coming out the Foley, rather benign now that I think about it.  Perhaps I have a subconscious fear of doing other people’s dirty work, such as cleaning up bodily excretions, which typically are left to the nurses, not the doctors anyway.  Perhaps I hate starting off at the bottom with the scutwork.  Who knows?!

What’s next to haunt my dreams, a patient going into anaphylaxis?  A patient waking up and popping up in the middle of surgery?  Laryngospasm during extubation (this actually happened a few weeks ago)?  What if I was the patient on the operating table and all of the above happened, plus more of the unthinkable? … {Shivers} …

Do I still want to Anesthesia?  Absolutely.  I loved my clinical experience, and would love it as a job I would want to wake up to every morning!  No bizarre dreams will deter the clear and solid path I have settled on.

First Day in India…

… I moved into my new flat for the next month with the minimal baggage I was carrying, basic travel-sized goods and essentials:  2 blouses, 3 black leggings, 1 PJ coffee colored leggings, 2 NYU T-shirts, 1 tennis T-shirt, 1 blue shirt, 1 light cardigan, 2 long-sleeved shirts to ward off angry mosquitoes, 2 pleasure reads, 1 journal, OFF! bug spray, Neutrogena sunblock, shampoo, conditioner, NYU toothbrush and paste, and such. Unbelievable for a month-long journey, n’est pas?

We arrived at the apartment by 8:00 am and plopped on a bed for a quick nap. I was simply happy to be reclining on a soft, flat surface and not some claustrophobic-inducing plane seat. I suffered through the person in front of me reclining into my personal space, wailing babies, and snoozing unnaturally upright. I’m not like an elephant or cockatoo that can sleep perched and upright.

… AND I fell asleep for 12 hours. I shouldn’t find this surprising anymore, speaking I can fall asleep at any hour, in any setting, in quietude or noise, and for long durations. The last time I pulled a stunt like that, I was jet-lagged from China and slept for 17 hours. This came a close second place in my all-time awkward sleep cycles.

You would think I could not fall asleep later that night. Oh, no no… I still slept that night, albeit uncomfortably. For the next few nights, I was continuously bothered by shadows in the dark room and howling dogs outside. Another day, I woke up in the morning, only to intermittently fall asleep until 5:30 pm. I have a major problem getting too comfortable reclined in a bed, whether it’s just reading or watching dramas or studying… Mauvaise idee! Certainly I’ll never have issues with insomnia or jetlag, since I quickly adjusted and assumed a normal cycle (at least in India) after a bizarre weekend.

Stuck in Sleep

“To Sleep… Perchance to Dream, Ay There’s the Rub…” (Hamlet)

Here is my very first morbid post, writing it while listening to the Delilah show and 106.7 LiteFM.

Last week, something strange happened to me. I was asleep in my bed, or I thought I was. I woke up in the dark and saw some faint white shadows along the ceiling above me. “Faint white shadows” sounds awfully like floating ghosts. In my half-asleep mind, I felt myself trapped amidst paranormal activity, like in that creepy mockumentary blockbuster. The natural instinct for a girl was to scream, which I tried and failed. Here was the freaky part: I could not move or scream. I was paralyzed in my sleep. My arm was locked against my sides, my voice disembodied. I could not twist my torso or turn my head.  My eyes still wide open, I saw the swiggly white ‘smoke-like’ shadows above me. I wanted to shriek and cry, but I was paralyzed and petrified to the bone. I could only lie there, helpless, scared, and alone. A few minutes felt like a stretch of time. Eventually, I fell asleep, because I woke up the next morning with a fuzzy recollection of the previous night’s happenings and fear of the unknown. I know all this sounds bizarre, speaking that I was in deep sleep, but this whole sleep paralysis phenomenon is real and chilling.

The Nightmare by Henry Fuseli (1781)

The first time I learned about sleep paralysis was in my college Child and Adolescent Psychopathology class. There, I learned about the human sleep cycle for the first time. And now that I’ve been studying the Neurobiology of Sleep and Wakefulness for my Neuro final, I can integrate my learning and my personal life.

Why do we sleep? We have an internal clock called the circadium rhythm, controlled by a suprachiasmatic nucleus. We maintain homeostasis, regulate temperature and energy, and consolidate learning, memory, and daily activities.

Sleep occurs in stages (here goes the Greek alphabet again…):

Awake: Beta waves –> high frequency and low amplitude waves

Stage 1: Theta waves –> drowsy feeling, right before falling asleep; waves become more synchronous

– This also occurs when you are doing routine activities where not much thinking is required, like driving a car on the LIE or jogging. It’s like being on autopilot. Here is where I tend to tune out and daydream, allowing my creative drive and fantasies enter my conscious thoughts.

Stage 2: Sleep spindles and K-complexes–> synchrony begins and real sleep sets in

Stage 3: Delta wave –> slow, mellow waves

Stage 4: More delta waves –> DEEP sleep; here is where nightmares and sleep-walking happens, which I’ve had the pleasure to experience in bygone days.

– My body really likes this stage. I sleep like a hibernating bear, sleeping through storms of the century, fighting couples outside my dorm room, friends playing Mah-jong or Smash-Brothers, etc… This stage is my friend =)

– There were many occasions where I’ve felt like falling out of the sky, only to roll out of bed and flop on the floor. That’s why I asked my roommate to take the top-bunk junior year of college, so as to prevent any emergency room runs for a concussion.

REM: (aka Rapid Eye Movement) –> higher amplitude and lower frequency; MANY important things happen at this stage

-This stage is NOT my friend after what happened last week, but it is a necessary part of our sleep/wake cycle

– like the awake state, as there is an asynchronous pattern

– dreams happen, the ones you remember (in Stage 3/4, your dreams are fuzzy) but also cannot act out

– I learned that in REM sleep, the ‘naughty’ nature of dreams emerges because the inactive prefrontal cortex does not hinder the ‘down and dirty,’ primitive parts of the limbic system (amygdala for emotion and hippocampus for memories).

Non-REM physiological changes: autonomic slowing, episodic & involuntary movements, slow eye movements, and decreased muscle tone/blood pressure/temperature/respiration/heart rate/erections.

REM physiological changes:  autonomic activation, rapid-eye movements, skeletal muscle paralysis, pupillary constriction, twitching of digits, and increased blood pressure/temperature/respiration/heart rate/metabolism/erections.

Now back to my night. My child psychiatrist professor from college asked the class during that sleep lecture, “Has anyone woken up during REM sleep… It’s pretty freaky, you know, the feeling of being trapped and unable to move!” Back then, I thought “Is that really possible, to wake up during REM sleep?” Speaking that the brain is active, it can happen, in normal people or with psychopathology, such as narcolepsy.

I looked this up on the Internet. You can wake up either in deep sleep right before REM sleep (predormital) or upon awakening (postdomital). Sleep paralysis can be associated with panic symptoms and vivid hallucinations, which explains my urge to scream and run after seeing some funky things in the dark.

Chinese charm for longevity and health

I told this story to my sister and she asked me, “Are you sure you weren’t hallucinating?… Oh by the way, do not do that again. Do get your rest and be careful! Are you wearing your jade wu lou?!” I was like “Huh?,” to which she directed me to some cultural references, particularly the East Asian school of thought. I got the chills when I read about the Chinese explanation for sleep paralysis, termed “鬼壓身 / 鬼壓床” (Gui Ya Shen/Gui Ya Chuang). The term translates to “ghost next to you or on your bed.” Chilling, n’est pas? Japanese and Korean culture have a parallel interpretation, that an other-worldly, ghostly presence is about the sleeping person. In Japanese, it is called kanashibari (金縛り), or “bound to metal.” In Korean, it is called gawee nulim (가위눌림), or “being pressed by a scissor.” Why do Asians explain everything with references to the evil spirits and ghostly manifestations? Watch J-Horror, and you’ll notice all ghosts look the same with bloody unfinished business and surprises for the living. Aish!

 

 

Gross Anatomy: The First Patient

First year Gross Anatomy has come to a blissful close.  Throughout the semester, I’ve been drowning in anatomy.  I’ve been floundering in anatomy jettison: weekly entertaining lectures, down & dirty dissections, quizzes, the big midterm, embryology, lab practicals, and an even bigger final exam.  Now that my 3-day marathon of exams for this one class is over, I feel… liberated and triumphant. Well not quite yet, I still need to know my grades.

At Stony Brook, the class is termed “The Body,” like supermodel Heidi Klum’s sexy nickname. Except, the class is not at all sexy or like a glamorous Victoria Secret’s runway show. When I first started the class, I felt like I was walking through a horror movie. I tend to be squeamish, only recently getting used to the sight of blood and body parts. Hey, if I chose the medical path, I have to be a brave soul.

Walking in that first day, I panned around the fluorescent-white room to see a sea of white body bags. Scrubs on, hair up, scalpels ready, we began to unzip. Inside, a freshly-preserved human body awaited the first cut. The first dissection- the back muscles and spinal column. Glad I did not have to look in the cadaver’s face yet, I twitched at the slightest touch and yelped when bits of flying flesh hit me. Methodically, I peeled back the flap of skin and let the scalpel shave through the flowery fascia. At first glance, it looked like we were trapped in a sick movie scene, with all the 1st-year medical students slicing away at tissues and hacking away at the vertebrae like lumberjack carpenters. And yet, we all have the remarkable opportunity to delve into the human body to see the beautiful interplay of vessels, organs, musculature and pearly aponeurosis.

Oh, the many anatomical sketches I’ve drawn. Never have I enjoyed so much coloring and doodling since kindergarten and elementary arts & crafts. In preparation for lab and personal perfectionist tendencies, I have belabored over countless drawings of organ systems, muscle relationships, circulatory networks, and nerve pathways. It’s almost like embarking on a road to become medicine’s next top Netters. However, the man is just too talented, his drawings are absolutely legendary, and I can never dethrone the master of paper and syringe.

Anterior Thoracic Wall-My doodles

Netter's Anterior Chest Wall-See the difference?

Let’s not forget those endless hours glazing over the Netters’ atlas, especially when it came to studying the difficult pelvic region. I felt a little embarrassed studying a rather private area in a very public library. I also wonder who modelled for Netters when he sketched the naked macho-man flexing his biceps brachii and pectoralis major…

"Smell my neck"

To conclude, this is how I studied for my crazy finals. That weekend, I chilled in my room, freezing and freaking over the impending anatomy exams. The weather was terrible just by hearing the cries of the wind and tree branches whiplashing the icy air. I lounged on the living room couch, memorizing answers to old exam questions. That was not at all comfortable, because I was practically sinking into the couch. The next day, I migrated to my bed. $Bad idea$ You would think I learned my lessons from college, when I used to be lazy and study off my bed. Next thing I knew, I woke up at an awkward hour and still have a whole binder of notes to study before that day’s midterm. That’s why I always forced myself to either 1) stay up all night or 2) study in a stimulating environment, like libraries or Bobst. Now, that’s more difficult because 1) I live off-campus, 2) I do not have a car, and 3) it’s Stony Brook and nothing is within walking distance except the parking lot and Waldbaums.

So I camped out under my covers all day, bundled up in a sweatshirt and yoga pants. I felt like a catepillar in a cocoon. Aside from food and bathroom breaks, I was like the Energizer Bunny high off Chinese green tea. My bed was littered with diagrams and notes, Netter’s Atlas, and Stern’s Core Concepts & Clinical Sidelights. I spent a whole Monday staring at pictures of the head and neck, driving into my head every cranial nerve function and pathway. Oy… why did the facial and trigeminal nerve have to be so complicated? I should not be complaining, because technically, I would not be smiling or furrowing or feeling a titillating cheek rub without them.

Well, as it may have been guessed, I fell asleep next to Netters and Core. By around midnight, I started feeling drowsy and sleepy. I still had loads to study, but I told myself, “Okay, set an alarm for 4 am, wake up, and study some more when you feel refreshed.” That was not a realistic goal at all, because I kept sleeping. I woke up at 4 am, looked at a few questions, then flopped onto my pillow again. Then I woke up at 6 am, only to study for barely 5 minutes and fall asleep again. I did not actually pick up my lazy tushy until 10 am, when I finally found my focus. Well, by then, I felt more screwed than prepared. For some reason, I still can do well under pressure and cramming the morning of an exam. I believed in myself. The same episode happened again the next night. But hey, at least I got my sleep =)