Infectious Disease, Last Week

Things are going well with Infectious Disease still.  We've had a few interesting developments.  One of our patients, the homeless young female patient who has had altered mental status and been in full restraints for the past week and has systemic Methicillin-Resistant Staphylococcus Aureus infection has actually started to come out of it.  From the start she had altered mental status and we haven't been able to get an MRI to see how her brain is functioning, so we have had no way to know how her brain was doing.  Through this we were speculating that she had bacterial vegetations forming throughout her body that could be throwing clots to her brain, and she even grew MRSA in her spinal fluid, so it could have been forming microabscesses in her brain as well.  Not to mention the huge abscesses in her iliacus and piriformis muscles (anterior to the spine in the lower back, behind the abdominal viscera) that started the whole deal.  I think none of us were really expecting her to ever come back to mental awareness, and we had not seen her in anything resembling a lucid state since we started treating her.  

Today she woke up.  

For her it almost seemed like nothing ever happened - just saying "I'm hungry," and "I feel tired," like she'd had a really long nap.  Calm and tired, not thrashing about or pulling at her tubes or anything like that.  No alarm yet, maybe has a little bit of a drugged look (understandably), and we still don't know the extent of the damage of this week of MRSA sepsis, but she's lucky she had my preceptor on the case for her infection and such a good team of ICU specialists.  It's amazing - there are some patients who you really don't know if they will recover who somehow bounce back, and then there are others who look fine and are ready for discharge and they die that evening.  Definitely drives home how unpredictable medicine can be.  

That's not to say that I think we should do everything in our power to keep a human body running when it is beyond what a clinician would estimate is "the point of no return".  Some absolutely septic patients, with multi-organ failure, and other comorbidities like diabetes and obesity are still getting specialty bone scans and send out labs even when their lactic acid level is at 14, they are on 5 different pressor medications and their blood pressure is still not in control, their stats are steadily dropping, and they're on a ventilator.  There is a time and place for hospice and palliative care.  Some points that indicated that perhaps our homeless young woman might recover were the following: she was never on a ventilator, her laboratory values were never all that particularly horrible, she was young, AND she wasn't obese, diabetic, or suffering any other comorbidities that we knew of (aside from drug abuse).  It's amazing what diabetes and obesity will do to your survival rates in a hospital.

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.

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.

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.  

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.  

Elective Rotations and Sports Medicine

After a lot of phone tag with various physicians and emails going unanswered for a week or so, I finally got in contact with two infectious disease specialists - one works at NorthBay Medical Center in Fairfield, and the other works in Oakland.  I got them both on board to do one of my elective rotations each, so I'll be in Fairfield in October, and in Oakland in December.  Another little perk is that the Oakland physician is taking the last week of December off, so I'll have something like a winter break.  It should also be a good variety, since one of the rotations is at an HIV/AIDS clinic and the other is more hospital based.  

As far as Family Medicine, I'm working on a case presentation that I'll be doing on September 20th - it's going to be about 45 minutes long, in front of all the doctors in the family medicine department.  Oie.  I found an interesting case we saw of a woman with a lot of problems coming in for new onset myalgias (neck, hip, arm) and the idea that my preceptor went with was early Herpes Zoster, so she prescribed some prednisone and did some viral assays.  About a week later though, the patient went to the ER for Bell's Palsy, which in the context of Herpes Zoster would be Ramsay Hunt Syndrome type 2.  She still hasn't had a skin eruption yet, but we shall see if we get more information back about her in the next few days.  The overall theme of my presentation will probably be acute myalgias, the workup, likely candidates in a primary care setting, and of course the actual patient case.  The hard part will be organization and fitting it into a 45 minute time slot, since acute myalgias is a huge topic.

Also I think I've figured out what kind of preceptor-student relationship I had had in mind for rotations.  My first preceptor was nice, but not very approachable, hard to read, barely spoke about anything, and wasn't very open to teaching with me asking questions - he was more into the old fashioned pimping style of him asking everything until I don't know.  So, that was the example of the "hard to read" preceptor.  Then my current female preceptor is nice, kinda touchy-feely, a little holistic, so that's a nice contrast.  The sports medicine doctor ( a guy ) is almost too friendly, with a lot of topics of conversation that go outside of the office.  The other male doctor I am with sometimes seems more like I had envisioned it - nice, tolerates some question asking, talkative but mostly about patients or conditions or clinic-related topics without it feeling too "strictly business".  

As for today, I saw a good variety of things - saw a woman with breastfeeding-associated DeQuervain's Tenosynovitis, with the characteristic positive Finkelstein's test.  I also saw two ends of the spectrum of rotator cuff injuries - honestly, it seems like half of the patients (at least) who come into the sports medicine office have rotator cuff problems - makes me want to keep my rotator cuff muscles strong so I don't end up having problems with that.  I feel bad for the older people with those problems.  The one end of the spectrum was someone who kept trying to exercise even while doing physical therapy and ended up coming in with an entirely inflamed shoulder, with subacromial bursitis, biceps tendonitis, and rotator cuff weakness/tenderness.  On the other end, there was a woman with focal pain on her lateral posterior shoulder, and an X-ray showing that her humeral head was about a centimeter higher up than it should be in her glenohumeral joint.  When I did the exam, I got kind of excited about finding a significantly positive sulcus sign - which is elicited when you exert downward traction on a person's humerus by pulling their elbow gently to the floor.  On the uninjured side I didn't get much but on the other side her shoulder went down a ton, had a visible dimple on the shoulder, and a lot of cracking (crepitus) - it almost sounded like I was dislodging it from a stuck position.  That was the first time I had tried that test since our sports medicine practice.  The patient was really surprised, and I think it made it more likely that she would do her physical therapy, since there was a significant, noticeable difference in her joint.  

Long Day of Surgery

Well, another surgery day is at an end. I was first-assist for a cholecystectomy and a thoracotomy plus decortication. The cholecystectomy was fine, went about as expected - and I sutured up two of the short incisions and they looked quite nice. The thoracotomy is where it starts getting interesting - it was on this 22 year old obese autistic individual, very obese. We had to go through 4 or 5 inches of fat to get to his ribcage where we had previously inserted a chest tube to drain pleural effusion. The guy had a really bad pneumonia infection and it had caused empyema, so we needed to go in, break a rib, spread his rib cage a bit, and detach as much of the pus-covered fibrinous exudate as we could - it was really remarkable how much there was. Imagine peeling really glued on labels off a glass beer bottle, except instead of glass it's lung tissue and the label is dense clotted blood, pus, exudate, and fibrin material. It took a total of 2 hours to do the surgery.

After that I observed a cholecystectomy, but this was kind of an odd case because the woman had a standalone piece of liver, about 2 inches by 1 inch by 0.5 inches, living by itself on her gallbladder. It was really weird, it had it's own blood supply and everything. At any rate, same procedure took place - removed the gallbladder along with that tiny chunk of free-living liver, and stitched the woman up. She took a half hour to come out of anesthesia and even then she was too weak to do much so they decided to intubate and let her sleep and recover overnight.

In other news, my car needed to be repaired, battery/alternator trouble and the cost is gonna be about $2,000 - really painful to think about. At least I have loan money for this sort of thing - unfortunately they still haven't disbursed the majority of my loan money because there is some problem with my stafford loans over at the main university headquarters on the east coast and they are waiting to hear back from them. If I don't hear anything tomorrow, I'll bug them again.

Also, I contacted an infectious disease specialist who works with AIDS patients and he told me to email him so we could set up the rotation - I haven't heard back yet, but hopefully tonight or tomorrow he will respond and I'll know if/when my infectious disease rotation will be. I'd really like to do that, we shall see.