Functional anatomy of the tongue

The muscles of the tongue can be divided into two groups, extrinsic and intrinsic.

The extrinsic muscles are named for their bony attachments.  Their function is to control the position of the tongue within the oral cavity.  The extrinsic muscles are:

1. Genioglossus, which attaches to the mental prominence of the mandible and acts to protrude the tongue,
2. Hyoglossus, which attaches to the hyoid bone and acts to depress and retract the tongue,
3. Styloglossus, which attaches to the old-school stylus and acts to scratch up some wicked beats,
4. Cranioglossus, which attaches to the head-bone, and acts in amateur local theatre.

The intrinsic muscles of the tongue have no bony attachments and are named for their function, which is to modify the political affiliations of the tongue.  The intrinsic muscles are:

1. Tyrannoglossus, which acts to increase centralized control of government,
2. Populoglossus, which acts to decrease centralized control of government,
3. Socioglossus, which acts to move to the tongue to the Left,
4. Conservatoglossus, which acts to move the tongue to the Right, particularly in New South Wales.

The innervation of the tongue is complex.  Motor control of the tongue is primarily via the 59th cranial nerve, the Diagonal Tongular Nerve (CN LIX).  Sensory afferent fibres from the anterior 2/3 of the tongue, carrying gustatory sensation for salt, sour and umami, course westwards along the state boundary, evading authorities for weeks before holing up in an abandoned farmhouse and dying in a shootout at the end of a protracted siege.  Sensory afferent fibres from the posterior 1/3 of the tongue, carrying gustatory sensation for sweetness, bitterness and elbo cheese, join the lingual nerve, before diverging acrimoniously and writing a tell-all memoir.

Vascular supply to the tongue is via the lingual artery, a branch of the external carotid artery, which is a branch of the carotid artery, being the twelfth exit from the Southern Expressway, but only between the hours of 2pm and 1am.  Venous drainage occurs in the reverse direction between 2am and 1pm.  This schedule is inverted on weekends and public holidays when the tongue is expected to be more active in the evening.

Clinical spills

It's kind of hard to believe, but soon I'll be a doctor. 

I've done all of my assessment.
I have eleven days left on the wards.
Two weeks after that I'll graduate.
In January I'll start working.

And yet, frighteningly, I am unable to diagnose a simple case of tonsillitis.
Despite having been in the ear-nose-throat team for just shy of a month.
And it was in my own child, the Hatchling.
I shone my torch down her gullet and said, "Nope, those tonsils look fine".
Well, apart from the exuded pus, apparently.

I'll give myself part marks for actually thinking of it and checking for it, but zero (obviously) for my actual clinical skills.

Majestically swept back

Here's a time-saving tip: you don't need to keep track of whether or not you need a haircut because eventually people will start reminding you themselves.

I was late yesterday morning and intercepted my team halfway through the ward round.  I apologised for being late and said that I'd been racing around trying to find them.  The Big Boss said to me, in his kindly voice, "That's okay PTR, we can see from your hair that you can walk very fast indeed."

A nifty quote

"It is interesting to note that patients who have been stabbed do not usually describe the pain as stabbing." - Pocket Clinical Examination, Talley & O'Connor, 3rd Edition.

Confidential

A couple of weeks ago I got roped into a teaching session for the 2nd year students by my surgical team.  They were running a rotating series of 5 or 6 learning stations for about 8 students per group, and since one of the registrars was away they got me to run a station instead of him.

In the other stations the big boss surgeons sat the students down and presumably taught them surgeony things like the best bottle of red between $50 and $75, and who the best trainers for racehorses are.  My station, bizarrely, was a test.  Tough luck if you got the test first before you'd been taught anything.  Not that it really mattered because the test didn't count for anything.

It seemed to me to be a pretty pointless exercise.  Also, watching people do tests is not my idea of fun, so as each new group came into my room I would explain that they could choose between doing the test by themselves or having us all sit around and talk about the answers.  To their credit (I thought) the groups all chose a middle path and had a crack at it themselves before having a discussion afterwards.

The discussions were good. I would let them air their theories about what they thought was the right answer and why, and I made sure that everyone contributed at some stage, before I would tell them what I thought was the right answer (note the important caveat there - I was not given the answers) and why, and then we'd discuss it some more.  I got the impression they all found it kind of useful and somewhat interesting.

I was told to collect the papers but made an executive decision that the students might as well take them home instead, seeing as I pretty much told them all the answers anyway.  As a result I had this almost surreal conversation with one of the surgeons:

Indignant Surgeon

Where are all the test papers?

PTR

The students took them home.

Indignant Surgeon

How will the students know what the right answers are if we don't mark their papers?

PTR

I suppose they could always look things up.

Indignant Surgeon

But they'll pass the information on to the other students in other groups who haven't sat the test yet!

PTR

The test doesn't count for anything, right?

Indignant Surgeon

We'll have to change the test.

To recap, he was upset that students might go away and learn something, and even worse, might help other less motivated students to learn something too!  Silly me - I forgot that medical education has nothing to do with educating people.  It's actually all about making sure that people feel bad about how ignorant they are.

I was discussing this with my Smaller Half and she pointed out the additional absurdity that there is no way in hell that a surgeon is going to sit there and mark 50 exam papers that don't even count for anything.  I suggested that it would probably have been passed down to the Fellow, who would dump it on the Registrar, who would delegate it to the RMO, who would handball it to the Intern, who would sling it to me.

So not only was I able to actually teach people something, I also thwarted a stupid plan and saved myself some dull work in the process.  Win-win-win.

Tiling, Seville, Spain

Sticky dates

Centrelink, from whom all benefits do flow, is ever so slightly frustrating because their payment timetable does not accord with my Smaller Half's pay week.  This means that I need to analyse her paysheets and divvy them up into the overlapping fortnights into which Centrelink carves up time.

A similar situation exists in the unit that I'm with at the moment at the hospital.  Rather than having a weekly schedule so that I can turn up to the operating theatre and say, "If it's Wednesday you must be Mr Farkas", they have a four-weekly schedule.  So there are meetings that happen on Wednesday of Week 2, or Friday of Week 4.

Although this complicates my life slightly, I can cope with it.  It gets annoying though because there are other meetings/events that happen on the third Thursday of the calendar month, for example.  So there are clashes with the four-weekly timetable which means that things are Never As They Seem.

Again, this is something that a somewhat intelligent and sophisticated person such as myself should be able to deal with.  Unfortunately the Big Boss Surgeon is quite old and grew up in Tsarist Russia and still denounces the Gregorian calendar as a communist conspiracy.  As a result, whenever he's around we all have to pretend that it's thirteen days in the future.  This meant that not only did I have to come in on a Sunday, I also missed out on my birthday.

I got so fed up with this that last week I didn't bother to go in at all.  When I turned up this week I was going to tell them that I'd been at home preparing for the Mayan apocalypse, but since I'd been using a reconstruction of Antikythera Mechanism to calibrate my diary I'd erroneously thought that it was going to happen on November 3 2011 rather than December 21 2012.  Unfortunately I'd forgotten that it was Daylight Saving so I was an hour late and they'd already finished the ward round and gone off for coffee so I missed them entirely.

Frosty

So today's lesson for beginners is this: when the surgeon walks up to the team and asks, "Is everyone good?", the wrong answer is, "I'm great thanks!"

They are not interested in you.  They are asking about the patients.

Timing is everything

Registrar

So what structure do I need to be careful of when operating just here, PTR?

PTR

The facial artery?

Registrar

No.

PTR

The external carotid?

Registrar

No.

PTR

The cervical branch of the facial nerve?

Registrar

No, the marginal mandibular nerve.

PTR

?!?

[Enter Consultant]

Consultant

So, PTR, what structure should the Registrar be careful to preserve in this area?

PTR
Hmmm.  The marginal mandibular nerve?

Consultant

Yes, that's right. Excellent!

[Exit Consultant]

PTR

So - what's this marginal mandibular nerve then?

Bohemian rhapsody

People often ask me why I decided to study medicine.  I usually lie to them and tell them that I wanted to help the helpless, bring hap to the hapless, and so on, especially if it's an interview panel or they are dressed like the Three Amigos.  But the truth is that I did it because I really like funny names.

Medicine is chock full of conditions, diseases, syndromes, body parts, microbes, and devices that have been named after people.  The number of things is so vast that all of the Bakers, Browns and Smiths got in early, meaning that the field is wide open for people with unusual and sometimes amusing names to be enshrined for all posterity.

So it helps me while away the hours thinking about how Reiter's syndrome is different to writer's block, or why Kawasaki disease has nothing to do with motorcycles, or how Wohlfart-Kugelberg-Welander disease has the word "fart" in the middle of it.  Snigger.  This is PTR's First Law Of Comedy: funny names are funny.

The problem comes though when you find out that the condition that you're laughing at the name of is serious, horrible, and generally dire for all concerned.  This is PTR's Second Law Of Comedy which contravenes the First Law: dead people aren't funny.

Fortunately, I have recently discovered PTR's Third Law Of Comedy, which contravenes the Second Law: dead people are funny if they happen to have been officers in the Prussian army during the 1866 campaign against Austria in Bohemia.

As evidence, may I present Exhibit A:

• Verdy du Vernois
• von Wartenleben
• Schlotheim
• von Tumpling
• Finck von Finckenstein
• Prince Kraft zu Hohenlohe Ingelfingen

These names are fantastic, and in fact I feel a bit disappointed that they chose the military life rather than the medical.  Just imagine finding out that you've ruptured your Ligament of Ingelfingen, or that your doctor was about to slot home the Schlotheim speculum.  Now that would be worth the pain.

Eye opener

My new team starts at 7.30 a.m. which is slightly challenging for me, but no more so than, say, waxing my eyebrows.  It simply takes an effort of will to haul myself out of bed.

But from time to time my willpower fails me and I end up running just a smidgen late.  I was late this morning.  I stylishly swerved my car into the carpark and trotted towards the hospital entrance.  Glancing at my phone, I realized that I'd missed a call.

Oh no!  Perhaps it was my new registrar and she'd called me up to urge me to redouble my efforts to arrive on time.  Or perhaps to tell me that the notes I took yesterday were so good that I'd better take the day off as a reward.  Better check my voicemail.

My voicemail had a call from an mystery number - a man's gruff voice:
"When ya git outta the shower washin' that beautiful body of yours, wanna give me a ring?  Thanks darlin'."

Hmm.  I guess it wasn't my registrar after all.

Play it as it lies

The most useful thing I learned in my recent six week stint with the psychiatrists is that psychiatrists are doctors too.  Here's the evidence:

1. They know all about "Code Brown".
2. They get really annoyed at inappropriate referrals, such as the person with confusion due to an infection that the ED docs think is bonkers and should get detained and given anti-psychotic medication rather than something more appropriate such as, say, antibiotics.
3. Their handwriting is illegible.

With regard to point 3, although it's illegible, it does have the benefit of being voluminous.  They write so much that often you are able to get the general vibe of their notes even though the actual words are gibberish.

In contrast, the surgical team I've just joined, while they also have unintelligible writing, don't seem to be able to use sentences in their notes.  To be fair, this is probably because they are scribbling madly, desperately trying to catch up with the surgeon, who conducts the round so fast that windows are shattered by the sonic boom.

It's pretty intimidating getting thrown into the midst of this as a student because it means that anything in the notes is thruply confusing.  Not only is the handwriting terrible, the actual text is just bizarre abbreviations of things that you wouldn't understand even if it was actually written out in full.  On the round this doesn't matter so much because as a student my main tasks seem to be to hold the tongue depressors in case anybody wants to do some Playschool craft projects and to not get trampled underfoot by the aforementioned rampaging surgeon.

Clinics though - clinics are a different story.  Today I was given the job of taking notes, which is fine (in fact, the surgeon told me I was a "born note taker", which may actually be an insult, but anyway) except it means that I'm holding the notes and hence also have the job of flipping around in the previous notes and trying to answer questions about the previous appointments.

The surgeon would turn to me and ask something like, "What was the original plan when Mr Smith first presented last year?".  I'd find the page and see that it would seem to say something like, "P) OPO f/u A/S2 w C+R".  Now if you're roolly smart like me you can mentally adjust for the scrawlings and say, "Outpatient followup up in 1 month with a chest x-ray".  Which is fine. 

But the next line says, "2. FFfFt + ananas - ref/ chok", and what do you do with that?

I can't figure out what it means, nor even what it might mean.  The nihilistic part of me wants to throw caution to the wind by saying, "Klaatu barada nikto", just to see what happens.  However, that is not how you establish credibility on day 2 of a new clinical placement.  It's more suitable for a morning tea in week 5 when everyone already knows you're a bit of a nut.  So I simply say, "It looks like the plan was for fffffft, ananas and ref chok."

The surgeon pauses and stares at me long enough for my heart to skip two beats.  "Hmm, fair enough.  It wouldn't be my approach but I'm pretty conservative", he says, and carries on.

Roof, Seville

I've got your deposit right here

My Smaller Half and I want to buy a house.  But we've hit a snag - we have no money.

Apparently a few years ago there was a big stink-up because some chumps in the USA borrowed more money than they could ever afford to pay back, plunging the world into a screaming spiral of horror and causing a number of billionaire sociopaths on Wall St to temporarily lose their jobs.  As a result, Australia's pinko government rammed laws through parliament infringing my democratic right to borrow more money than I could ever afford to pay back, thus grossly offending my inflated sense of entitlement.  This country is stuffed!

After ringing 4 banks and 3 other non-banks (by which I mean non-bank financial institutions rather than other non-banks such as ice-cream vans or Belgian pederasts) I resigned myself to having to live in penury for another 3 months until those juicy payslips giving me substantially less than I used to earn in my old job start rolling in.  But then I got put onto a mortgage broker in town who turns out to have all sorts of tricky tricks up his sleeve, so maybe we're still in with a chance.  Actually it's not so much that he has tricky tricks, it's more that he seems to motivated by wanting to succeed, whereas the loan processors at the banks and non-banks seem to be motivated mostly by malice and spite.

We had a two hour meeting with him on Friday where he sussed us out and did some brainstorming of possible ways around the road blocks.  It was really interesting to watch a professional from another field work.  It reminded me of nothing so much as a good doctor taking a really thorough medical history.

For example, it's important to know what medications people are on (for both doctors and banks, but I'm talking about doctors now).  So you ask them, and they tell you.  And then you typically ask them about a whole bunch of medications that most people don't think of as medications, like the contraceptive pill, asthma inhalers, anti-inflammatories and other analgesics, insulin, and so on.  It's easy to start thinking that people are pretty dumb for not telling you this the first time.

But lo, yesterday the shoe was upon the other foot.  He asked me if I had any debt.  No, I said, quite proud of myself.  Any credit cards?  Oh, yes, sure.  Any HECS debt?  Oh, yes, that too.  Oops.

And, just like a doctor, sometimes he used words and jargon that I didn't understand.  It's incredible how many times I've seen doctors walk up to a patient, dump a mouthful of polysyllabic Graeco-Latin blah-blah on them, then consider the job done.  It's excruciating to witness, and now I know how difficult it is to get it to stop when it's done to you.

It's really hard to ask questions about what something means when you can't remember what the thing was even called.  I'm sure he was horrified when I got my Third Party Mandated Lending Policy Exception mixed up with my Conditional Approval Pending Party People Mandate.  Or something.  It'd be like confusing your cardiorenal syndrome with your velocardiofacial syndrome.

I reacted by just calling the different things "The First Thing" and "The Second Thing" and so on.  I must try that on Monday morning when I turn up to my first surgical ward round of the year.  I'm sure it'll be looked upon kindly.

Praise me

I was feeling generous and expansive, so I was talking up my Esteemed Colleague who is going to be replacing me after tomorrow in this unit.  The registrar obviously found me unconvincing in my universally positive comments, so he asked me if there was anything bad about him. 

"Why yes," I said, "He compulsively makes inappropriate jokes."

"Oh," said the registrar, "He sounds just like you."

Nutri-brain

Registrar

So once the mRNA is produced, what happens then?

PTR

I have the word "ribosome" in my head.  But maybe that's just something in my breakfast cereal.

As it turns out, ribosome was the word I was after.  The other word that I was afraid I was confusing it with was "riboflavin", a.k.a. vitamin B2, which is essential to life because it makes your pee yellow.  All those nutri-grain ads on the idiot box when I was a kid nearly derailed my medical career.

My vulnerability to the all-pervasive cereal advertising industry in lieu of any kind of actual medical training is regrettable.  But still, I can walk the walk and talk the chalk or something like that when I have to.  Check out this picture from a talk I gave earlier this year on tuberous sclerosis:

It's complex but I think it captures the essence of what I was trying to say, which is that I had no freakin' idea of what is really going on but it's probably too complex to matter in an informal talk.

Not really

Checkout Person
That'll be $87.76

Smaller Half
The register only says $28.76

Checkout Person
Oh, you know what I mean.

I wasn't aware until now that I was an apologist for sexual predators

Nurse

There is a well-known case here in this city of a psychiatrist who had sexual relations with no fewer than five of his patients.

PTR

That's terrible.

Nurse

No, it's not.

PTR

?

Nurse

It's unacceptable.

Extreme child care

Most mornings, I drop the Hatching at child care then come in here to the hospital.  Yesterday morning, it was the child care workers who dropped the Hatchling - literally. 

I got a phone call around 10am, it was the child care boss.  My first thought was that she was ringing me up to rouse on me for not paying our bills.  This is a splendid example of a conditioned stimulus.  The first thing she said to me though was, "The Hatchling is fine.  There's been a bit of an incident."  Good first line - I guess lots of parents would assume that disaster had struck as soon as the child care centre calls them at work, so it's sensible to defuse things immediately.

But "an incident"?  That's too vague.  I suppose she said it was "a bit of an incident" so I wasn't thinking of sieges and hostage-taking so much as perhaps she's had her finger bitten or something.

Anyway, it turns out that two other kids mugged one of the child care workers while she holding the Hatchling, with the result that the Hatchling plummeted earthwards.  Fortunately she landed on the child care worker so there wasn't much of an impact.  Nevertheless I scurried up the hill to go give the Hatchling a cuddle.

As soon as I walked in the door the poor woman who'd dropped her burst into tears and started begging for forgiveness.  "YOU BITCH, I'LL SEE YOU IN COURT, YOU'LL NEVER WORK IN THIS TOWN AGAIN!", I screamed, spittle flying from my lips.  No wait, that was the feedback I gave my supervisor a few rotations back.  What I actually said yesterday was, "It's okay, she's not hurt, accidents happen, you must have got a real scare but it's all okay now."  That made her cry even more. 

Once the staff realized that I wasn't going to burn the place down in righteous fury they all got kind of manic with relief.  They launched into a detailed account of how it happened, where it happened, who was standing where, what similar incidents had occurred in the past, re-enacting how people had rolled around on the floor in desperation trying to catch the babies that were raining from the ceiling, and generally creating a ruckus.  It was quite a scene so I beat a hasty retreat, shouting reassuring words to them as I went.

I reckon they probably have a policy that if anything bad happens to any of the kids, they call the dad first.  Dad turns up, nobody is missing any limbs, so he jiggles the kid a bit and takes off again.  Saves time for everyone.

Bark, Flinders Ranges