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...  

Last Day of Actual Surgery and Didactics Presentation

So today was my last day doing actual surgeries - tomorrow I have my last day of clinic with the orthopedic surgeon.  We did two arthroscopic surgery repairs, one of them was a rotator cuff repair which I hadn't seen before.  Another was an arthroscopic knee meniscal repair, and the other two were hand surgeries: carpal tunnel release surgery and a ganglion cyst removal.  I still get along great with the surgeon and his PA, so I'm not worried about my grade for this rotation.  He isn't very book-focused and they always joke when they see me studying so much so I assume they think I am intelligent enough.  

Throughout most of today I was reading and rereading my presentation for today.  As part of our third year clinical rotations, we have to attend didactic lectures on Tuesday, only an hour usually.  Every other Tuesday, one or two of us present, and we each have to do a total of two presentations by ourselves - one on a topic that we can elaborate on, and another on a selected clinical case.  My turn was today, and my topic was Psychiatry, so I chose Major Depressive Disorder because it is applicable to everyone.  I was worried about a lot of things - whether I would run overtime, whether I would bore everyone by talking about antidepressant medications, whether I was saying too much or too little, whether people would be unresponsive or not know how to answer my quiz questions, and whether people are bored to death with depression, because I remember we had a lot of lectures about that at Touro.

Anyhow, I gave my presentation - I got a slight boost of confidence because I went over it orally beforehand and managed to get it down to 19 minutes and 30 seconds, so I wasn't as worried about going overtime.  So I gave my presentation, people seemed to pay attention and like it.  Basically everyone was answering my pharmacology quiz questions, so it was definitely sticking.  When I got feedback, it was essentially a unanimous response that it was the best presentation all year, was really informative, I sounded confident and knowledgeable, had all the information that everyone had been craving, was varied, kept attention, etc.  The physician who attends all the didactic sessions and grades our presentations agreed that it was the best all year and was even at the next caliber level for what he expects from us - that it is the kind of presentation one could expect at the professional level at a real conference.  

Needless to say, this was awesome.  Honestly, I feel like I'm a decent presenter.  I try to convey my enthusiasm for a topic and hopefully drag a few unwilling audience members with me, but it worked out great. I used PowerPoint animations, humor, color coding, quotes... this was exactly the boost I needed to help me keep going on through studying boards and rotations.  I think I'm going to be happy and charged up the rest of the night!  Man.  

Week 2, and Week 3 of Orthopedic Surgery

Orthopedic surgery is continuing to do well.  Since those two hip replacement revision surgeries, which apparently are only done once a year or so, I have assisted on several arthroscopic procedures and today we had 9 hours of surgery - no waiting around - two total knee replacements and two total hip replacements.   Apparently I am getting a lot of good experiences, since some of these procedures are not done all that often during a single 4 week rotation period.  I definitely feel privileged to be able to handle shards of bone and help drill into patients' dislocated hips.  

One of the patients today had had a hip fracture a long time ago and was immobile at his hip joint because his bones had not set properly and had accessory bone growth within the joint socket and around it, essentially cementing his femur into his pelvis.  It would be neat to see him in post-op after he realizes he can move his hip again on that side.  

Something interesting I found was how the procedures are very step-by-step - everything is cut based on relative positioning and they have a ton of pre-made accessories that they attach to the bone to help guide their cuts.  Also, when boring into the shaft of the femur to place the metal rod, they first make a small hole, then start with the smallest metal rod, and then build up incrementally to the size they wish and it is all very precise.  It is quite neat.  

My preceptor also seems to think I am coming along fine - he and the PA both think I pick up things fast and my preceptor was pleased with my more recent patient presentations and assessments.  He is also very relaxed - the PA as well.  They both have similar political/religious/cultural views (which I of course let them voice first before chiming in at all - I'd rather not take the risk of striking a bad chord) so that helps make for good conversation in the OR.  I have also been allowed to help put respiratory equipment into patients with the anesthesiologists - just the throat dam (not sure the name), but it's still useful to get a little familiarity with the oropharynx.

Week 1 Orthopedic Surgery

This rotation is pretty cool.  The clinic days are generally easy, I shadow him, present the new consults, I get to look at X-rays, and he encourages me to take time to research various conditions on my computer (I get a little work station).  I also get a lunch break for an hour and a half sometimes to study for the boards.  I can even do practice questions at work.  I also ran into my last preceptor (infectious disease) at the main hospital when we were there for surgeries, so I got to visit with him a bit and he updated me on some of the last patients we had seen together.

Surgery days: I get to study in between surgeries - I review through the USMLE First Aid Step 1 in between surgeries, and I am listening to Goljan lectures in the car. 

As for the actual surgeries themselves, they are pretty interesting.  The laparoscopic procedures remind me of kelp forests because the golden glistening tendrils of intra-articular fat and meniscal tears have this fluffy look to them and they are waving back and forth in the water due to the irrigation.  On Friday I got to assist on two total hip revisions - very complicated procedures, the surgeon who is my preceptor was working with the UCSF doctor who was his attending in residency.  Apparently the UCSF doctor only assists on surgeries if they are more challenging cases.  In these cases, we were 'revising' the prosthesis, as in taking out the prostheses that were implanted in the hip and femur, shaving out the concrete and re-forming the implant sites, and then using a combination of cadaver bone, current bone, new prostheses, metal cables, screws, and cement to reattach them.  It's amazing that it produces a functional hip at the end.  We have to wear knee-high foot covers over our scrubs (normal surgeries you only need foot covers to the ankle), and also these heavy plastic face shields that you wear like a helmet that circulate air inside your helmet.  There's a lot of blood spray, so that's what those are for.  Unfortunately, the strap around my head was giving me a pretty bad headache in the second surgery, and this whole weekend I have had a mild-severe tension headache from my neck straining against the weight.

Another week starts tomorrow, hopefully it will be educational as well as productive in terms of board review.  

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.