Liz's Medical School Journey

Everybody is talking about the “Swine Flu” lately.  Since I’m studying Microbiology- Infectious Disease (Micro-ID), this seems to be the perfect time to add my own commentary.  So here goes…

H1N1 or Swine Flu- what are we supposed to call it? Well, I think either is fine as long as you know what you’re talking about.  H1N1 is its proper influenza name, a name which is given based on type of each glycoprotein on the surface of the virus envelope (to visualize glycoproteins, imagine Lego blocks super-glued on the surface of a globe).  N=neuraminidase and H=hemagglutamin (only 3 types of Hs and 2 types of Ns exist in humans, but other animals like birds have more).  The problem with H1N1 is that it can easily be confused with previous H1N1 influenzas (like the Spanish Flu pandemic of 1918 and its resurgence in 1970′s).  The virus genome encodes 12 proteins (only two are H and N), and this H1N1 is different.  It was born from a human virus, a bird virus, and two pig viruses (hence the “swine”).

Will H1N1 be the next pandemic? No, definitely not.  First of all, most people over 25 have some immunity, and everyone’s immunity will soon be expanded by the vaccine.  The other “good news” is that H1N1 is susceptible to antiviral medications that already exist, so if you’re American with a normal immune system, chances are that it won’t get a chance to kill you.  Although a $45-65 antiviral treatment is too expensive for most people and countries, if you can read my blog- then you have access to antivirals.

What’s with all the hype? My idea is that the world is trying to get ready for the next big influenza pandemic, which no doubt will happen in the next 50 years.  New virulent strains are rare, but with all the invisible viral recombinations that take place inside cells daily, probably a new type will form with Hs and Ns that humans have never seen before.  Then, there would be a real pandemic scare!   Public health awareness about the dangers of influenza and importance of prevention could stop future pandemics.  Plus, hand-washing is easy with alcohol-based rub (which obliterates the influenza envelope).  So, let’s take hand-washing to a whole new level!  If the media wants to make everybody believe that H1N1 could be pandemic, so people will be more concerned about hygiene… well, it may very well save millions of lives later, so who am I to argue with that?

How long can H1N1 survive on surfaces? 2-3 hours

Will the H1N1 vaccine be safe?  This is a common concern because of how fast the vaccine has been manufactured and mass-produced.  But actually, the H1N1 vaccine is just like the regular flu shot.  So, yes, it’s safe (unless you have an allergy to eggs or another protein in the vaccine, which most people don’t).  And it is certainly safer to get the vaccine than not.

Should you halt all your trips to Mexico? No.

What kills you when you die of the flu? Excellent question!  I was wondering myself- oh wait, that’s obvious since I am writing all these questions!  Turns out influenza doesn’t kill you.  It depletes the immune system, so bacteria invade.  Then, usually people die of pneumonia, respiratory failure, or other opportunistic infections.

Any other questions?  Add them below and I’ll do my best to answer.

Last week I finally finished a book I was reading for leisure—The Spirit Catches You, and You Fall Down by Anne Fadiman. Two people independently had recommended this book to me.  And in fact, I thought it was a wonderful combination of history and cross-cultural perspectives as a Hmong family tries to understand the Western medical approach to their daughter’s epilepsy.  I found this book at a perfect time since I am fascinated about cultural sensitivity and ethics in medicine, and I am currently studying neurology.  However, the story struck me personally as well because I, like the main character Lia,  had epilepsy.

This week I have lectures and reading about epilepsy, and I cannot deny that it is unique to be studying something as a medical student, which I once knew mainly as a patient.  I’m not sure if I should share this with my classmates or not.  Obviously, it isn’t something visible to most people, and the culture of medical school does not encourage sharing about personal hospital stays, surgeries or diseases.  Little do my classmates and I acknowledge that we who become doctors, must at some point be patients also.  After reading many essays written by doctors, I conclude that the experience of being a patient usually has profound impact on medical professionals.  Instead, as medical students we learn that studies show it is important not to mention our own medical experiences with patients, and it seems that this extends to become a vow of silence about any health challenges we face ourselves.

As I have had the chance, I have been trying to break this silence, and let people know that I had epilepsy for two big reasons.  Foremost is epilepsy carries stigma which needs to be challenged.  Most people have a narrow view of the disease that likely includes somebody shaking violently, mental retardation or psychological problems.  And second, I want people to know because I spent so many years of my life trying to erase epilepsy from my past.   As soon as I outgrew my seizures, I removed my medical alert bracelet, did not mention it to my friends, and became furious when my parents brought it up.  Now, I feel guilty about my shame, and I want to be able to embrace it as part of who I am.

Over the past few years I’ve learned that NO human has perfect health all the time.  I should be glad that one of my health defects came as a relatively mild seizure disorder. I am in good company with others who allegedly had epilepsy (such as Isaac Newton, Vincent Van Gogh, Agatha Christie, Napoleon, Charles Dickens, Michelangelo, Leonardo da Vinci to name a few).  Despite this, I still remember the day that my neurologist told my mom that “people with epilepsy do not become doctors” (yeah right, doc).  Obviously, despite being a neurologist, he had never personally gotten to know anybody with epilepsy.

If my neurology readings are accurate, then many people with epilepsy do suffer from comorbidities like developmental delays.  However, please do not forget that the majority of people are normal and happen to have seizures.  As far as I know, my partial-complex temporal-lobe seizures, which started at age 9 and disappeared by age 16, are not rare.  A Newsweek article earlier this year said epilepsy is more common than breast cancer, and that 50% of children outgrow it in a few years.

Now that I am learning about the cortex, my memories of seizures start to make physiological sense to me.  My seizures were accompanied by an aura (a strange smell) a couple times.  Yet mostly they started with the sound diminishing around me (like a volume dial was turned down) and other auditory stimuli that sounded like voices.  Sometimes I also saw colorful “blobs.”  As soon as this started, I was usually frozen until I lost consciousness.  At that point, I don’t remember anything except waking up (1-2 minutes later) and being scared and confused about who and where I was, and who the people were around me.  Yesterday I learned that this phenomenon is called “jamais vu” and occurs because the temporal lobe is close to the emotion and memory processing centers of the brain.

I can never forget what it was like to have my brain take over my mind.  Additionally, I cannot forget the challenge of EEG’s and getting an accurate diagnosis, or the  powerful side effects from the medications that included projectile vomiting, severe sedation and cataplexy (loss of muscle tone while laughing).  Our lecture materials make the diagnosis sound easy… epilepsy is diagnosed by 2 or more seizures and an abnormal EEG.  Yet, seizures aren’t always obvious, and EEG’s are scheduled into short time slots (seizures inconveniently cannot be scheduled).  Thus, many patients may be unsure if they are having seizures and they may not have abnormal EEGs.

If I feel this way about epilepsy, then every disease I am learning about must have a depth of complexities and contradictions.  The strange things that the brain can do and its delicate balance of neurotransmitters are fascinating, but simultaneously surprising and confusing.  Today, for example, I saw videos of people who seemed normal, but had specific deficits such as the inability to recognize faces or read.  Most surprising, however, is watching the brain rationalize behaviors—to make sense of what’s happening or how one is behaving, even when it doesn’t make sense.

So whether it’s a seizure or idea, the brain is self-programmed to control us, rather than vice versa.  Epilepsy forced me to admit powerlessness over my brain long ago; this lack of control or individuality will ultimately allows me to feel more spiritually connected.  These lessons from my disease- epilepsy- remind me that medicine is less simple than what I must learn, and gives me reverence for all my brain lets me do.

During this summer, I was preparing myself for medical school by doing foolish things, and I read a popular teen vampire novel called Twilight.  This week Twilight the movie premiered, although I haven’t had time to go see it yet.  However, it was during this same week at one of my final biochemistry lectures that I learned something very interesting and unexpected… vampires are real!

What?!  Why didn’t I hear about this disease before?  Oh yes, that’s probably because people who actually have this genetic disease would rather not be related to vampires.  Given that vampires are considered evil by many people and were tortured outcasts of society, this is a touchy subject. The legend of vampires exists nevertheless, and there is a real medical explanation for how it may have originated.  Therefore, I feel compelled to share this intriguing knowledge.

It makes sense that before science was able to explain strange genetic diseases and symptoms, people assumed that they were connected with the devil or a result of certain behaviors or diet.  In fact, when I lived in rural Ukraine, pregnant women refused to cut their hair, thinking it would cause birth defects.  Yet, now we know that genetic defects are often the result of a tiny, unlikely mistake in the duplication & division of DNA.  A single tiny rearrangement or deletion can cause a lot of strange things to happen- it’s amazing that most of us come out looking “normal.”

The possible explanation of the vampire legend is one of seven types of porphyrias, which are all diseases in the synthesis of heme (the compound in blood which carries oxygen and carbon dioxide to keep us alive).  Heme is synthesized in the liver and bone marrow.  There are eight steps, four of which take place inside mitchondria and four in the cytoplasm.  Therefore, there are multiple opportunities for defective enzymes and build up of intermediate products.

The interesting thing about the intermediates in heme synthesis is that they contain many benzene rings.  When these rings are oxidized, they can absorb light and appear to be colored (think of purple-yellow-brown-greenish bruising when heme is broken down right under the skin).  When there is a build up of intermediates, it causes purple urine, red and fluorescent teeth, and extreme sensitivity to light rays.

The type of porphyria believed to have started the legend of vampires is called porphyria cutanea tarda.  It leads to a build up of products which cause a variety of problems.  First, people suffer from extreme anemia, so they are very pale.  Additionally they have red and fluorescent teeth, which can look pretty strange.  The intermediate products in their blood can oxidize to become insoluble when exposed to sunlight.  This causes pain and blistering in their skin, so they would try to never go outside in sunlight.  Also, drinking fresh blood, which somebody may have figured out, could relieve the neurological symptoms.  This was a genetic defect, so it stayed within families.  Since these people were probably outcasts from society, they may have married cousins causing the disease to proliferate faster.

None of this is proven fact because nobody knows where any supposed “vampires” are buried.  Otherwise, it would be possible to dig them up and perform a genetic test.  Also, this explanation doesn’t explain a fear of garlic or why you have to put a stake through their hearts to kill them.  This is an extremely rare disease.  Yet, it’s interesting to know that we understand so much about the body now that we can go back in time to solve medical mysteries.