The Spinal Exam, Sort-Of-Not-Really

I’ve written before in “The First Patient!” that a major component of the medical school curriculum is the physical diagnosis course. PDX, as it’s called, is a long-term course that teaches medical students the hands-on skills needed to examine patients. It’s kind of important.

As I mentioned, we generally have a lecture on a part of a physical exam on a Friday afternoon, and the next week we partner up in our simulation center and practice on standardized patients. Usually this lecture goes well. For instance, last time we met for PDX lecture, we talked about the eye exam. Our professor gently talked us through the very basic anatomy for ten minutes, since we’ll go in depth on the eye later this semester, then walked us through the exam. She took care to emphasize difficult points – for example, to find the optic disk you should follow a blood vessel until you see a bunch of them come together – and made everyone feel confident that they could perform the exam with a little supervision.

(The following week’s practical didn’t go so well, but that’s for another story. I was blind for like six hours after we practiced because I have “good pupils” and everyone wanted to use me as their test dummy.)

Anyway. This coming week we’re doing the practical component of the back exam, which means that last Friday we received a lecture on how to perform it.

In theory.

When the class last Friday began, our course director introduced the speaker who would give the lecture – a nationally renowned spine surgeon. Homegrown at my medical school. Made sense.

He threw up his first slide: SPINAL ANATOMY. White text, blue background. No bells and whistles. Okay, that’s aggressive, but that’s what you get with surgeons, right?

I downloaded the slides and started flipping through as he put on the microphone and got set up. I counted eighty slides. EIGHTY?! I looked at slide 77. Still spinal anatomy. What was going on?

The professor began his lecture. The first slide made sense – I recognized most of the words, like “kyphosis” and “lordosis.” But then he moved on to the next slide, entitled “OCCIPUT.”

What in the hell is an occiput? I looked to the girl sitting next to me and raised an eyebrow. She looked back blankly. I briefly thought an occiput might be a kind of fish. Looking around the room, I realized no one else had a clue either. Under the word “OCCIPUT” was the following:

  • Foramen Magnum
    • Clivus or basion
    • Opisthion

You understand that exactly as well as I do. Befuddled, we sat in silence as The Man At The Front Of The Room talking at us – I no longer considered him a lecturer insofar as he was more of a tormentor – ran through his eighty slides over two hours. Other highlights included:

  • A fifteen-minute talk about “the path of the VA.” Both my roommate Ryan (of #Shredded fame) and I thought, for fourteen of those minutes, that VA stood for Veterans Affairs. Like, you know, the hospital. For military people.
    • VA stands for vertebral artery. If you cut it during surgery, you die.
    • Hey, I learned something from the Man At The Front Of The Room!
  • There is such a thing as a pedicle screw. How you put it in to someone’s spine is important and it looks messy. More research is required.
    • I got that tidbit of information from a slide that says, “A ponticulus posticus broadens laterally” (emphasis his). I don’t know what a ponticulus is. Or a posticus. Both sound like Roman emperors from The Gladiator.
  • We had a slide containing a diagram of the trapezius muscle. I KNOW WHAT THAT IS! It hurts when you do pull-ups or attempt to use that weird rowing machine that makes the obnoxious noise in the gym.
    • Also we dissected it in one of the two anatomy lab sessions we have had so far. (Two. Anatomy experts we are not.)
    • Immediately following that slide, The Man At The Front says, “this is irrelevant, really, you don’t need to know this.”
    • Shit.
  • To test the motion for your C8 spinal nerve, you ask the patient to make a motion that identically resembles grabbing a large, well-formed pair of boobs. This is the only spinal nerve test I remember, and the only spinal nerve test I will ever remember.

We eventually realized that The Man At The Front was reusing a lecture he had clearly been using for years to introduce neurosurgery residents and fellows to relevant anatomy and basic procedures. The material was approximately 498 lightyears beyond what we were capable of knowing, so most of us just sat there and tried not to laugh.

At the end, The Man At The Front demonstrated a full neuromuscular exam (not what we were doing in simulation that week, but notable because it included the aforementioned boob-grab demonstration) and dismissed the class.

Within six minutes, we received an email from our course director, who had been sitting in the back watching the whole time. The subject was “TO ALLAY ANXIETY…” and in essence said, “Yeah, don’t worry about… well, any of that.”

He went on to explain that there would be fourth-year medical students to show us how, and walk us through, a *basic* back exam. Emphasis his. By basic, he presumably meant “an exam performed by someone who is NOT bent on waiting until you’re unconscious to slam a handful of sterile screws into your vertebrae.” (Get it? Bent! Eh?)

Like The Man At The Front.

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