Thursday, October 27, 2011

Infectious Disease, Week 3

Things are still going well - this week we have another student hanging out with us.  He's a fourth year from my school, and apparently one of the top of their class - his board scores are probably 98th percentile and he's getting interviews for residencies in places that are competitive even for MD students, and normally impossible for DO students.  Needless to say it's a mixed bag - on the one hand now I have someone who has a ton of information who I can learn from and get tips for fourth year.  On the other hand, he's a genius - which is kind of intimidating.  On the plus side, he doesn't have an insufferable ego and is pleasant and nice, so that's good.  He's also very tall, about as tall as my preceptor and they are both over 6 feet tall, so I feel pretty short compared to the two of them.

We have been talking a lot about rickettsial diseases lately.  We had a patient come into clinic who was previously diagnosed with Lyme disease, Batonella, a couple other rickettsial diseases based on a tick bite 20 years ago and some doctor wanted her to go down to Monterey and pay for a 45 day infusion of antibiotics.  We all agreed, after the patient left, that she's probably being scammed - it's really a shame, because diseases like Lyme disease CAN have a chronic and nonspecific presentation - occasional fever, joint pain and stiffness, abdominal and cardiac problems.  When diseases have nonspecific presentations like that, the rate of false positives and hypochondriasis and money making by shady doctors goes through the roof.  

As far as interesting patients - our necrotizing fasciitis patient from the prison had had a surgery to debride his infected arm, but it wasn't enough and the bug was extremely resistant to antibiotics.  He developed a classic necrotizing fasciitis rash across his chest, and had tense bullae as well.  He died later that day.  We had another patient who was brought in for various reasons but one was vancomycin-resistant enterococcus endocarditis complicated by aspiration pneumonia (where you inhale stomach contents along with acid and possible bacteria and it damages your lungs or predisposes to infection).  The endocarditis was challenging because it was resistant to vancomycin, as well as a bunch of other major antibiotics.  We were treating with linezolid, but the course of treatment for endocarditis requires 6 weeks of antibiotics and we can't use linezolid that long or you start damaging the optic nerves.  Also, Daptomycin was considered but it is inactivated by lung surfactant so there wouldn't be good coverage of the possible aspiration pneumonia.  That patient also died later.  

Today is another round of patients in the ICU, then rounding on inpatients, then we go to another hospital to check up on patients and talk to the pharmacy staff about antibiotics.  Yesterday was a long day, hopefully today will go shorter.

Friday, October 21, 2011

Busy Day in ID

Today started off pretty busy.  I was at my morning rounds at 8:30 as is routine, and I wrote down the overnight reports of the patients.  One of them caught my attention as being a patient who had been downstairs on the normal inpatient floors.  We have been caring for two patients with Clostridium difficile infections and one of them wasn't looking to good and the other was looking better.  Unfortunately the one who was looking better yesterday ended up in the ICU overnight and was basically circling the drain.  It was really sad because he looked like he was getting better there, and he had been alert and talking and fine the previous day.

Right as my preceptor and I gowned up and went in to our decompensating patient's room, he told me to go to the room two doors over - that the guy had just coded and it would be a  good observational experience.  So I took off the gown and watched them go through all the Advanced Cardiac Life Saving procedures that I had trained in - they were doing a PEA (Paroxysmal Electrical Activity)/Asystole procedure, where the patient has flatlined and they are doing chest compressions, rescue breaths, and injections of Epinephrine every 2 minutes.  It was surprisingly by the books, no one was panicked, but there were definitely a lot of people.  There were imaging people in the hallway waiting to come in and do ultrasounds or x-rays of the heart/chest when anyone got tubes placed, and the defibrillator was ready.  You don't shock a flatline though, so they were basically going through the cycles of compressions and injections.  

By the time the code finished, I turned around to join my preceptor and we ran into the whole family of our C. diff patient, and we discussed his condition, and the family wanted to take him off life support.  It was pretty clear her was fading fast - his blood pH was down to 6.85, and the normal range is 7.35-7.45.  So, in a very short amount of time two ICU patients in the same area both essentially plummeted.  

The rest of the day was spent checking out our other patients and we discussed AIDS regimens and Pneumocystis jiroveci pneumonia.  This weekend I am going to check out the infectious disease society website and look up treatment protocols for a few things.  We have a fourth year (from my school?) joining us on Monday, so that should be interesting - maybe he will have some helpful hints for rotations and preparing for residencies.

Tuesday, October 18, 2011

Week 2 Infectious Disease

Well this week is off to a good start - we had a nice morning where he let me be to look up information on all our patients.  I reported sufficient information to him, so that's always good - I hate to come up short.  One of our patients who has a history of Chronic Lymphocytic Leukemia has upper lung lobe pneumonia of some kind and when I looked up his information I didn't see the positive quantiferon gold test for tuberculosis (he comes from an endemic region).  When I went to check in on him he hadn't yet been transferred to isolation, so then when I learned about the test then 10 minutes later when we went in to see him together he was in isolation and we were wearing our face masks.  

My preceptor told a funny-creepy story today.  When we were discussing antibiotic therapies with the pharmacists, a patient came up who was 100 years old and in a persistent vegetative state, and the daughter is refusing to let up on aggressive treatment.  It reminded my preceptor of a patient he saw some time ago who was brain dead, and had been for months, and the son refused to let them stop treatment, despite the man's mother being on a ventilator, and essentially brain dead.  The difference between persistent vegetative state and brain dead is that the former is specifically nonfunctioning of the cerebral hemispheres (higher thinking), while the latter includes the brainstem (basic respiration, reflexes).  So one day he was doing a status check on the brain dead patient and saw something on the patient's earlobe - it was a maggot.  Apparently somehow a fly had gotten into the mouth and/or ear and laid eggs and there were maggots in the throat/mouth and ear.  Kinda adds new meaning to someone being 'brain dead'.  

I also had a mini-victory today - we were talking about one patient who had a few trichomonads on her urine analysis and he asked me what the treatment is for that, and as he was adding, "do you have your Sanford guide on you?" (which is our booklet for antimicrobial therapy) I just answered without skipping a beat the first line and second line treatments.  I guess he didn't expect me to know off the top of my head, so I was pleased with myself, even if it was a super easy question for me.  

Sunday, October 16, 2011

California Association of Family Practitioners conference

Well, this weekend I have been in LA with a friend and attending the CAFP conference.  There has been a lot of discussion about how Family Physicians get a bad rap, and how they need to improve their image and reputation for the public, patients, other physicians, etc.  They went over the things to do when applying to residencies, went over the timeline for things.  The next most beneficial thing was talking to the residency program directors - the things they emphasized the most were...
  • Doing a sub-internship (Sub-I) at their facility
  • Choosing rotations that offer good inpatient training
  • Interviewing well and going with your gut
It was nice to know that they don't emphasize board scores very much, and that your rotations make a bigger impact.  I asked around about what programs that are local that they think give good rotations, and so I will be getting in contact with those people and preparing my rotation applications - the good ones fill up fast.  I don't want to be stuck with outpatient.  Only problem is I may be stuck with really long commutes if we move to Davis in February (e.g. if I want to do Peds at Oakland Children's Hospital).  Driving back up to Northern California in a bit - I have my family medicine lectures on hand!

Thursday, October 13, 2011

Infectious Disease Elective, Week 1

I just finished the first week of Infectious Disease - it is pretty neat.  I like talking with someone essentially ONLY about bugs and drugs.  So much more fun than getting pimped on things I have no clue about - and it is great for finding the holes in my bugs and drugs knowledge.  Our day is as such - in the mornings we usually hang out in ICU for their morning rounds, and he chimes in for patients who are on antibiotics - a lot of his job is managing patients on multi-antibiotic regimens to make sure they are all medically necessary so as not to promote bug resistance.  After that we round on his personal patients or check out consults.  Most of them are pretty standard, but some of them are fevers of unknown origin, and most likely infectious but we can't find the cause so that's always fun.  

He gave me a New England Journal of Medicine drug study publication to review and discuss with him.  Also I am going to start writing SOAP notes next week, which should be fine - I'm not particularly nervous about that.  I've done a lot of SOAPs, and while ID SOAPs will probably be a little different, it should be easy enough to adjust. 

Tomorrow I am driving down to LA with my boyfriend to stay at a friend's place while I attend the California Academy of Family Practitioners conference for residencies and education - I should be able to learn more about what is going on in residencies and I can interact with residency directors and talk to them about their programs, their requirements, etc.  I'm not sure how it will go, but hopefully I'll have some free time for socializing.

Also I am in the midst of signing up for my Step 2 exams and planning out my study regimen - I've decided to take the USMLE Step 1 sometime between December and February, and I'll be starting questions soon.  I was doing Step 2 questions, but if I really want to maximize the chance that I will match somewhere in the Bay Area, then I really need to make myself as competitive as possible.  We shall see how it goes but as long as my two digit score is over 80 I will be okay.  It's a bit stressful, and money, but it will probably help me prepare for Step 2 and it will give me some focus now.  I have two electives and a relatively chill surgery rotation for the rest of this calendar year, so this is a good time to study.

Tuesday, October 11, 2011

Starting Infectious Disease

Well, I have started infectious disease - it mostly involves going around to patients with suspected infections and monitoring their antibiotic regimens, laboratory cultures, etc.  The doctor is very nice, he is fresh out of his fellowship so he's closer to my age I think.  We have another student joining us next week, and he's also lenient about me taking days off (specifically for a doctor's appointment and for driving down to LA for the California Academy of Family Practitioners conference).  I spend a lot of time learning bugs and antibiotics, which should be good stuff to know.

In the meantime, I'm checking out residency programs that are nearby - I emailed two of them.  One of them said they take both COMLEX and USMLE, no difference between them, they just want a good score, and they look for a two digit score of 80 or higher, and I'm over 80, so that's good.  Not MUCH over 80 but hopefully there won't be too much competition - that tends to play a big role.  I'm going to try emailing the students who matched there and see if they have any suggestions or are willing to share their scores.  Family medicine isn't as popular as other residencies so I'll have a better shot.

Also need to sign up for the physical exam portion of my step 2 exam.  

Thursday, October 6, 2011

Family Medicine COMAT exam

Well I took the COMAT exam today for Family Medicine - three of my classmates didn't know the date had been changed so they were lucky I contacted one of them the night before.  Kinda funny.  Anyhow, took the exam - it was very consistent with what I had been learning - some of the questions may not have been written the best, but I think the USMLE questions will be more challenging.  I'll go through those on my question bank soon.  The exam took me about an hour and a half, we are given two hours.  Other people were staying longer but I think it is because they were Internal Medicine, and that exam is a bit harder than Family Medicine.  

I found some good online lectures to listen to for Family Medicine topics, and primary care topics in general.  Quite nice.  I have a little bit of relaxing in store this weekend, since I am now between rotations.  Tomorrow is my last day of Family Medicine, so I need to ask my preceptor about a recommendation.  He will almost certainly say yes.  

Wednesday, October 5, 2011

FM 2 Week 4

This is my last week of Family Medicine, only a couple more days.  Thursday is my Family Medicine COMAT exam, so hopefully I'm ready for it - I've been listening to prep lectures.  Yesterday we went to a nursing home for my preceptor to catch up on his nursing home patients.  It was interesting, though mostly depressing.  A good number of the patients are unaware of things, and most have those childlike empty grins of Alzheimers, the nonverbal combativeness of Alzheimers, slow fogginess of normal dementia, shaking and mental confusion of Parkinson's, or if they're lucky a semi-lucid awareness of what is going on.  One lady/man (I couldn't tell what gender the patient was, to be quite honest) kept following us down the corridors in his/her wheelchair, calling after the doctor who examined his/her friend asking why we didn't examine him/her.  He/she kept grabbing my arm and trying to talk to me, but the person was partly deaf so it was hard to even talk to him/her.  The doctor and the chief nurse tried ignoring the person, but he/she was very persistent.  Eventually they talked the person down, but it was awkward for a little while there.  We also saw one lady who has a big fall risk who feels trapped at the nursing home, because she cannot go out unaccompanied and has no family nearby.  That was rather depressing also.

I start Infectious Disease at Fairfield next week, so that should be neat.  I checked my rotation schedule again and my second elective is still not arranged, so I re-emailed our coordinator and I guess she just hadn't noticed that I had attached two different forms when I emailed her a month or so ago, and so she tried to blame the IT department on it.  She better not cost me a'll be a big headache to have to find another place.