Pediatrics, Week 1

Well, I have started pediatrics.  It is generally not the most interesting rotation, but there is a lot of stuff to memorize and it requires more participation.  Also, since it is a regular schedule, where I have to leave at 8:15 and end up back here around 6pm, I am finding my energy levels waning quite noticeably.  I've decided I'm just going to have to bring an energy drink every day to drink between 8 and 12, and that'll keep me going decently well for the whole day.  Luckily they don't cost much more than a cup of coffee, so it won't break my bank.  

As far as pediatrics goes, the most common visits involve a kid with a bad cold - usually with "sinusitis" or a possible ear infection associated with it.  If it's more than 2 weeks or the kid has strong symptoms, we prescribe antibiotics.  Personally, I think we are prescribing antibiotics too much and if it were me then I would not prescribe them, but right now I'm the student and I don't want to rock the boat.  We also see a bunch of kids for their ADHD, or monitoring their doses.  I still don't quite know what to make of it yet, as I've never attended a group session where the kids are seen interacting with each other and I don't know from experience what "normal" child behavior is.  Then there are the endless well-child checks, at 2 months, 4 or 5 or 6 months, 9 months, 12 months, etc.  We check their developmental milestones, answer parental questions, prepare the parent for the next stage of development and what to expect.  We haven't had any crying kids yet, so I'm kind of surprised - they are all really compliant with the exam, especially with the ear exam.  They've also let me examine them without much problem, they're all pretty nice.  I'm sure we'll have some combative screamers eventually, but so far so good.  

In other news, I finally got my isotretinoin medications today - better known as Accutane, though I have the generic version.  The process is extremely involved, especially if you are a female.  First you consult with a qualified physician who is familiar with isotretinoin, the indications, etc. and you discuss whether it is the right option - you are supposed to have exhausted every other treatment first.  Next, you get this packet for "females who have the potential to become pregnant."  You are required to read through everything, sign and initial tons of papers, and register and answer questions online swearing that you will use two forms of birth control (primary method such as hormones, an implantable device, or injections, and a secondary barrier method like a condom).  You must then wait for 30 days, and get a blood test within 7 days of your next appointment.  At that appointment the doctor makes sure you've done everything you're supposed to and that your blood tests check out, and they give you the prescription.  Once you have that, you have to take your special ID card, after having filled out the questionnaire online and registered, and go to your pharmacy to fill the prescription - if they do not have the medication on hand, then you have to wait until the next day when they will have it.  So...today was that day, and I now have it.  Side effects (aside from pregnancy) include skin sensitivity, depression, stomach upset, liver problems, skin dryness.  

I have seen some uncommon things though, which is cool - like Henoch-Schonlein Purpura and Roseola.  Also saw a case of Fetal Alcohol Syndrome, which is horribly tragic.  

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.

3rd and 4th Weeks of OBGYN

Phew, it has been an intense couple weeks.  Have barely had time to think.  I'll start with my 3rd week (last with Preceptor #1).  As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds.  The most recent thing I can remember is my last day there - Thursday which lasted 24 hours.  We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am.  I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal.  She was somewhere between 12-20 weeks.  Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions.  Anyhow, that was interesting.  Then I slept for a while and got woken up for the delivery at the end of the shift.  My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta.  My preceptor sutured up the tears, of which there weren't very many, and we took care of that.  There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper. 

A few other things of note - I was following a patient who I had assisted on a delivery for.  She was a caesarean section because of a placenta previa.  As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression.  We took that out the next day.  There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor.  Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching.  That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2).  My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem.  It's more mentally stimulating and it's nice to have a little autonomy.  The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia.  Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone.  This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside.  At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations.  Last resort includes breaking the collarbone and/or humerus.  Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder.  The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy).  Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage.  Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months.  By the second day after the delivery, the baby was starting to move its hand and shoulder. 

Now onto today - a nice long 24 hour shift from 7am to 7pm.  This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time.  However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz.  Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia.  This one didn't have any real nerve damage though.  The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay.  From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy.  I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess.  We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results.  There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months.  No way to know at the moment - just gotta treat.  I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow.  More studying, wooh!

Call Night and Week 2

OB-GYN is coming along without much of a problem.  I had my on-call night, and I thought I had been warming up to the whole baby thing, but I think the first vaginal delivery was kind of the ideal situation, along with ideal family responses, and environment.  The call night started out with figuring out logistics essentially - talked to the doctor for the evening, and it was my preceptor and this other female doctor on call that evening.  They divide the night into shifts, and so my preceptor slept from 9pm-2am, and the other doctor got to sleep from 2am-7am.  Like all medical students, I wanted to show my enthusiasm, so I decided to spend as much time with the other doctor before caving into sleep.  We had a couple interesting cases.

First case - fetal demise in an orthodox Jewish woman, 3rd pregnancy (has two living children).  A couple things are wrong with this case.  First, she was inconsistent with her prenatal care and was taking a lay midwife's advice over going to prenatal checks with her physician.  The doctors that I work with at the hospital have made a distinction between the midwife nurses at their hospitals and the lay midwives who are not affiliated - that in the hospital, their threshold for thinking a baby is in trouble (and thus, needing to interfere with the 'natural' progression of a gestation and vaginal birth) is a lot lower.  As a result, the hospital midwives are more willing to consult a doctor about a baby's status, or suggest a C-section.  Anyway, the woman stopped feeling any fetal movement around 23 weeks and the lay midwife said that was "normal".  The woman finally comes into the hospital after a WEEK of her baby not moving and there are no fetal heart tones of course, so it's dead.  The second problem is that a lack of prenatal screens/ultrasounds didn't catch what is most likely an anencephaly (or lack of a head) on the baby.  It could have been caught a couple weeks earlier, but no.  People like to talk up natural traditional methods of health care, but there's a reason we have these tests.  The third problem with this case is the orthodox religion - mostly it just makes patient care more difficult, but they need to consult another rabbi (even though her husband is a rabbi) to determine if they can test the placenta (dead baby is definitely off-limits) for chromosomal abnormalities.  Often when a woman has a fetal death, it is reassuring and relieves guilt to know that the baby had a chromosomal abnormality or other problems inherent in the baby that would have made it nonviable no matter what.  

Next case of the night... this really pretty Asian girl, possibly Filipina, late twenties, on her third child.  Her husband was with her, kinda ugly, but I gave him the benefit that maybe he's just a really sweet supportive guy to win a gal like her.  She decided to go through the vaginal delivery without any epidural anesthesia, and she barely made a peep - she did a great job, trembled a lot, but delivered the baby pretty quickly.  Right after this, the husband essentially ditches his shaking wife and stands with his back to her filming the baby in the warmer with his phone.  Once or twice the wife seemed to try to get his attention but he either glanced briefly or didn't respond.  This went on for at least 10 minutes, the whole time I was in the room anyway.  There also wasn't anyone else in the room, no other family.  I never saw him go over and ask her how she was feeling, or tell her she did a great job - made my blood boil.  

Next case before I went to bed - 21year old girl, second pregnancy, husband was this short kinda meek white guy - she delivered like a pro too - she did have an epidural, but she basically had no problems.  The husband on the other hand just about passed out when he saw the baby crowning - he wasn't intending to look, he was walking around where we were to the other side of her and his face just went white and he just about fell to the ground right there.  It was kinda funny, but at least all the family were supportive, smiling, and the husband stayed next to his wife this time.  

After that I went to sleep and my preceptor called me when he had a new case - we did a few checks to see if any girls' water was breaking, interesting stuff.  Around 8am I was done and in the car.  

That was it for that week - yesterday we started in the clinic and I got to do some Pap smears and some prenatal checks where I measured the uterus size (to see if it was consistent with the gestational age) and checked fetal orientation and heart rate.  The first one or two were a little challenging to find the heart beat for me, but I think I've started figuring out where the baby's body is oriented, so I was spot on the last 3 heart rate checks.  We saw a woman with an expelled IUD - usually that doesn't happen to women who have had pregnancies, but apparently she was told she has a short cervix.  

Today had two surgeries - one was a mid-urethral sling insertion, which is to help with incontinence.  The woman was awesome - she was a feisty, energetic, humourous elderly woman.  It's always reassuring to see older people with such vitality!  So that surgery took 35 minutes, no problem.  The next one was significantly longer, a laparoscopic vaginal hysterectomy, on a woman with an enlarged uterus and multiple fibroids - had to cut it up a lot and bring it out piece by piece.  The doctor my preceptor was assisting actually thanked me at the end for my help because the extra pair of hands made it go a lot better than they were expecting.  Yay!  

Tomorrow is a morning/afternoon of surgeries, and then another evening of call duty - I think I will try to sleep when my preceptor does this time, since I will not have had all day to relax.

1st Week in OB/GYN

Well, almost done with my first week in OB/GYN.  The first day we were on gynecological duty, so we were seeing patients in the hospital for ovarian cysts, pyelonephritis, etc.  However, we did assist on two C-sections and I got to observe a vaginal delivery.  It feels very odd to see a family react to a "birth" in scrubs while surgery is still technically taking place (suturing everything up, still have half the environment sterile).  The vaginal delivery setting makes a lot more sense - the delivery I saw only took about 40 minutes too so that was a pretty quick delivery.  Watching the men is the funniest part because they look terrified and helpless at the same time - after all, it's not like they can relate in any way and they can't really participate in the actual process - she's doing it all herself.  Of the two delivery methods, I'd definitely rather do the vaginal one personally (with epidural of course) - it just looks a lot more impressive.  

The next time I was in the hospital we were rounding on patients and doing a lot of gynecological surgeries so several hysterectomies and salpingo-oophorectomies (tube/ovary removal).  Not the prettiest of surgeries...especially when they do a hysterectomy through the vagina.  Before heading into this rotation, I had no idea that OB/GYN doctors do so much surgery.  Anyway, tonight we are on-call from 7:30pm to 7:30am, so I best be getting off to that - should be interesting.  I like night time, and I'm packing an energy drink - I hear there will be many deliveries.  I will post about it next time I have a spare moment!

In other news though, I got my loan disbursement, so money is not a problem for a little while.  I emailed my school contact about year 4 rotations and I am still studying for the boards - Feb 4.  

Second Week at the AIDS Clinic

Second week is almost over - it's been interesting.  This week he started his inpatient rounds at the hospital, so we've been going to the hospital in the mornings and rounding on whichever of his patients happen to be hospitalized or cases that require his consultation.  Had a case of mesenteric venous thrombosis, which apparently is pretty uncommon so they have been doing a full coagulation disorder work up - protein C, protein S, antithrombin III, antiphospholipid antibodies, the works.  More and more data have been coming out suggesting that HIV infection in itself produces a hypercoagulable state, and thus people are more likely to suffer a thrombosis or a stroke simply because they are HIV positive.  It is not precisely known why, but they are looking into it.  

There have been a few altered mental status patients as well, and one who has a recurrence of toxoplasmosis in addition to esophageal candidiasis and other things.  Been seeing lots of patients with lipodystrophy, or abnormal lipid deposition due to the HIV medications.  A lot of the medications cause fat deposition on the abdomen and the neck, and sucks fat away from the arms, legs, buttocks, and cheeks, so they can end up with a very odd body habitus.  A lot of them come in for problems unrelated to the HIV, such as poorly controlled diabetes, or joint pain.  The doctor I am shadowing spends 45 minutes or more with most of his patients because he goes through a list of 20 issues, some of them pretty minor.  He is definitely very comprehensive - takes his time, makes sure to ask about every aspect of the patient's life.  Being a primary care physician for so many patients as well as a specialist looks quite challenging - especially since they don't have medical records so he still does a lot of writing up of charts and has to go to the hospital to sign for things.  

On Wednesday morning I got to attend HIV grand rounds at San Francisco General Hospital - the doctor I am shadowing as well as a UCSF HIV pathology researcher/lecturer and the Kaiser Permanente HIV management physician were on a panel to discuss some interesting cases and do some Q&A.  It was good that I had had a lot of discussions with the doctor about HIV before the panel, because otherwise some things would have been harder to follow.  At the end of this rotation I will definitely know all the combination therapies, as well as which drugs are NRTIs, NNRTIs, and PIs.  It's gotten easier already.  

Two things I have learned about on this rotation are HIV strain reversion to wild type, and protease inhibitor "boosting".  Because patients go on and off drug regimens when they gain and lose insurance, they can develop resistant strains of HIV - however, some of these mutations that develop decrease the fitness of the virus (similar to sickle cell increasing resistance to malaria but decreasing overall fitness/survival in humans).  Anyhow, while there are drugs exerting selection pressure, the mutants can survive and overpopulate the wild type, but when the drugs are discontinued the mutants die off and the wild type becomes the dominant strain.  Sometimes the mutant type is no longer replicating so genotype tests will not show any resistance patterns.  However, because HIV is a drug that integrates and hides in host cell DNA, those resistant mutants are usually still hiding somewhere in a cell in the body and can emerge again if you re-start therapy with the drug that selected for them in the first place.  This can make treatment a challenge.  As far as protease boosting, we were taught a list of 'protease inhibitors.'  One of the protease inhibitors is ritonavir, which I thought was like the other protease inhibitors, but turns out that it is not particularly effective at suppressing the virus, but acts to improve the effectiveness of the other protease inhibitors such as darunavir or fosamprenavir.  So that was useful to know - I was wondering why I kept seeing 3 drug regimens that had four drugs listed (including ritonavir, which they don't count as one of the 3 drugs).

Anyhow, one more day tomorrow - just hospital rounds in the morning - and then a 3 day weekend!

First Week at the AIDS clinic

This week I started shadowing an HIV physician at the AIDS Clinic in the city - the first day I tried driving and quickly discovered it would be a nightmare and is impossible to do for a decent price on a regular basis.  I figured out the BART schedule and the next day I came in that way - I have about a 15-20 minute brisk walk to the hospital, so that gives me a little exercise - I may start packing a change of shoes though in my backpack, don't exactly want to be walking several blocks in semi-heels or boots that are more fashionable than functional.  

As for the actual rotation - again pretty chill.  Most days I don't need to get there until pretty late in the day - 10-ish.  Some days even later - this Thursday I don't need to be there til 1:45pm.  We also get off relatively early.  And I get one day a week completely free, and Fridays he doesn't have patients in the afternoon.  The patients are mostly homosexual men with HIV - they are surprisingly compliant with their regimens - I haven't yet heard him give a lecture about how they need to be better about taking their medicines.

Yesterday I got to accompany him to a nearby hospital pharmacy where we met with a drug rep and my preceptor spoke about a new single dose multi-drug pharmaceutical that was FDA approved recently.  He says he looks at his main role as a health educator, and doesn't try to push one drug over others, that he doesn't speak for companies that wish him to be more heavy-handed in his talks.  At any rate, I got to learn a lot about Complera, and it's predecessor Atripla.  

Here's some of the medico-pharmacologic stuff that you may not be interested in but I will talk about nonetheless.  One of the major challenges with HIV treatment is that there are a ton of drugs, a lot of them have weird side effects, and a lot of the drugs have to be taken at various times of the day, making for a complicated regimen for patients.  Before Complera, there was only one single-dose multiple drug combination pill that could be used in patients with HIV.  Single day dosing is pretty rare in a lot of medications, and combination pills can be extremely useful.  The disadvantage with combination pills is that the dosages are fixed, so you cannot increase the level of drug A in combination ABC, you have to stick with the set dosages of A, B, and C.

Anyhow, a standard regimen for an HIV patient is two nucleoside reverse transcriptase inhibitor (NRTI)  class drugs, plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) class drug or a protease inhibitor (PI) class drug.  Atripla contained two NRTIs and one NNRTI (Efavirenz).  Efavirenz has a fair amount of side effects.  Anyhow, they came up with a new combination drug Complera, which is the same two NRTIs as in Atripla, but has Rilpivrine in place of Efavirenz - they are both NNRTIs.  Physicians also often add a protease inhibitor (plus a booster drug to increase it's effectiveness).  It was neat hearing about the differences between them, the restrictions.  We also got a free lunch, though apparently there's a new policy that pharmaceutical reps cannot provide catering to their events - another attempt to prevent there from being any "buttering up" to encourage use of the drugs.  I understand but if you are presenting during lunch time, it would be advantageous to provide a lunch...  

We also had a patient who decided he wanted to stop all his antibiotics that were treating him for Mycobacterium avium complex (a different species from Mycobacterium tuberculosis, which causes tuberculosis, and all species of Mycobacteria are notoriously hard to treat).  His reasoning: He has been getting magnetic therapy.  I immediately thought of the Penn and Teller episode about magnetic and other kind of hand-waving snake oil type new age medical treatments that masquerade as medical treatments but really just are, like the title of their show, bullshit.  I don't particularly object to gullible or desperate people trying alternative treatments, but I do object when these unproven, possibly dangerous, treatments are used in place of evidence-based medicine that WILL work!  Hopefully that guy won't have a recurrence of his infection, which may by this time be resistant to the antibiotics he was being treated with before...