As I mentioned last week, I’m currently taking a hybrid classroom/clinical duties course centered around immunology and the immunocompromised patient. I’ve just finished a week on the stem cell transplant unit, where most patients have received a bone marrow transplant to treat leukemia. In general, these patients come to the hospital for one of three reasons:
- To get their bone marrow transplant;
- Their leukemia relapsed;
- They developed an awful complication called graft-vs-host disease.
My attending this week was wonderful. He loved teaching, listened to my entire presentation, and always explained what the hell was happening. Since our official name was “Hematology/Oncology – Stem Cell Transplant Service,” I rarely had any idea what was going on, so this information was extremely welcome.
I had a great time. It was low-stress, even though I had no idea what I was doing and couldn’t pronounce about 75% of the medications we used.
I had a great time, that is, until Friday.
On my last day of the rotation, my wonderful attending decided that it would be Pimp The Med Student Without Mercy Day.
You would think that after a week on his service, he might ask me about stem cell things. The relative advantages and disadvantages of myeloablative induction versus reduced intensity chemotherapy, or the mechanism of action of blinatumomab, or whatever. You would be wrong.
Outside of our first patient’s room – who was hospitalized with the aforementioned graft-vs-host disease – he turns to me and goes, “Nate, do you remember your umbilical cord anatomy?”
“Um. There are two umbilical arteries and one umbilical vein.”
“Good,” he replied. <Silent self-fist bump.> “What is the name of the substance in the rest of the umbilical cord?”
I KNOW THIS. During first year, basically every medical student is shown the following picture of the umbilical cord:
Basically every medical student remembers this picture because of its uncanny resemblance to a cracked-out face. For some reason I also remembered that “Wharton’s Jelly” was the name of the intervening goo.
“WHARTON’S JELLY!” I answered confidently, still with no idea where this was going. The hematology fellow gave an approving nod.
“And what is Wharton’s Jelly made of?” the attending continued.
No idea. Time to make shit up! “Glycosaminoglycans and extracellular matrix?”
The attending, already prepared to move on to whatever quick lecture he had planned, stopped suddenly. “N… no. What? No. It’s mesenchymal stem cells, Nate, stem cells. We are the stem cell service.”
Should have known, I guess?
He then proceeded to lecture me on why mesenchymal stem cells could be used in graft vs host disease. Sure. Cool story bro. (The nerd in me was, actually, thinking, “cool!”)
After seeing the patient we walked to the next room. “Nate” – my blood ran a little cold at this point – “this patient has a spinal cord tumor. What spinal tract controls motor function?”
“The corticospinal tract.” My neurology clerkship director would be proud.
“Good. What about pain?” “The spinothalamic tract.”
This went on for three or four minutes, him pimping me on basic spine anatomy, which I violently hate, and me batting about 35%. The nurse practitioner looked at me sympathetically as I got yet another question wrong (on the rubrospinal tract, which if you care is a thoroughly useless tract with no real function whatsoever*).
Did this have anything to do with stem cells? No. No it did not. We are the stem cell service, but we are going to pimp the med student on vestigial bundles of neurons that are only important in kangaroos.**
*The rubrospinal tract is a small bundle of nerve fibers that go from the spinal cord to a small area in the brainstem called the “red nucleus.” The entire purpose of the red nucleus is that it is red. Seriously. It is physically a red circle. It probably does things. This is why it is a named thing.
**I have no idea if the kangaroo thing is true. I just know it is a useless pathway in humans.
No one knows or remembers this pathway because it is not an important thing to remember. In fact, if you google “rubrospinal tract” and click the first non-Wikipedia result, you get a 404 error. I am not making this up. I have no idea why I was pimped about it. It has nothing to do with stem cells, as far as I know.
Anyway. As we moved to the next patient’s room I could feel a cold bead of nervous sweat sliding down the middle of my back.
“Nate,” god. damn. it. “Nate, are you listening? Why does this patient with a recent stem cell infusion have back pain and leg weakness?”
I had no idea, but, you know, it’s the stem cell service so it probably has something to do with that. I’ve learned this week that when questioned on transfusions, the answer is usually “minor antigen mismatch,” for reasons still unknown to me. So that’s what I said.
“He had a minor antigen mismatch?”
My attending looked vaguely pleased with himself. “No. He has steroid myopathy. Steroid myopathy, Nate. He is on two grams of methylprednisolone. That is a lot of methylprednisolone!” He grinned widely. “So, what causes steroid myopathy?”
I gave up. “I have no idea.”
The attending grinned. “Correct!” He walked away.
What? The hematology fellow leaned toward me as we followed the attending and whispered, “No one knows what it means. But it’s provocative.”
Without missing a beat, my 50-year-old attending looked over his shoulder and finished, “Gets the people going.”