Thursday: Don't underdose pain meds in children. We have a tendency to look at kids as being small and feeble and are reticent to giving then the full dose of pain medications, even after adjusting the dose for their weight. But that's just silly! We wouldn't give them less antibiotics than recommended just because they're small and cute, so why would we make them suffer when it's perfectly safe to give them proper pain coverage? It happens all the time though, so we have to be vigilant and follow the evidence.
ThursdayIL: The enzyme asparaginase, which is used as an adjunct cancer therapy, can be produced both in E. coli, our typical enzyme-mass-producing organism of choice, and Erwinia chrysanthemi (recently renamed as Dickeya dadantii), a bacterium otherwise only known as an infectious agent to plants. If a patient is allergic to the E. coli variety, they get asparaginase-Erwinia.
Friday: It's frustrating not being able to put in orders as a sub-I. Of course, it makes sense legally and for patient safety. But as we are the pseudo-doctors in charge of our patients, when a nurse needs something for a patient, they page us, not the other residents who can actually write orders. So it ends up happening with frustrating frequency that we have a plan in place for some banal anticipated event that is delayed because I need to get an actual resident to switch away from whatever they are doing to open up my patient on the EMR (electronic medical record) to sign off on my orders. It seems like such a simple task, but since everyone else is usually taking care of sicker patients, my requests almost never take priority. Again, this is how it needs to be for many reasons, but that doesn't mean it's not frustrating.
FridayIL: The staging and grading of acute graft-vs-host disease (GVHD) is pretty complicated. Each involved organ system has four stages of involvement and then the grade is determined by either of two different systems that weigh the combinations of staging of each organ system. For example, both systems only allow for skin involvement in the lowest grade of the disease; even stage 1 involvement of the liver or gut automatically raises the grading. But if you have stage 4 involvement of any organ, then you are automatically grade 4.
I also learned a nice rule of thumb for pRBC (packed red blood cells) transfusion in severe iron deficiency anemia. You don't want to overload the heart and cause heart failure, so only transfuse at a rate less than or equal to the hemoglobin level (e.g. ≤4ml/kg/hr for a Hg of 4g/dL).
Showing posts with label pharmacology. Show all posts
Showing posts with label pharmacology. Show all posts
Tuesday, December 27, 2016
Saturday, December 24, 2016
WILTIMS #511: Enemy at the gates
Fever is a very scary thing in cancer kids. In normal kids, even though the technical cut-off for fever is 100.4°F (38.0°C), we aren't really all that concerned with an otherwise asymptomatic fever until it's consistently hovering a good deal higher than that (Reminder: please don't ignore your child's fever because of my silly blog; let your doctor make the call). But if you have no immune system, like kids receiving chemo or transplant meds, then your body has a really hard time producing the signals that lead to a fever. So, if one of these kids hits 100.4°, then it means that they are likely already quite ill, but not showing the typical signs yet. It's like if you're fighting a war and you have no more troops; just because you don't hear any gunfire, doesn't mean the enemy isn't advancing right to your door.
WednesdayIL: Though ECP does stand for emergency contraceptive pill (as I learned in my OB/GYN rotation), it quickly became apparent that that is not what the pediatric oncologist was talking about in regards to treating a young boy's graft-vs-host disease. In this case, it turns out, ECP stands for extracorporeal photopheresis, a method of essentially cleaning the patient's white blood cells. The idea is to remove some of the patient's blood, separate out the immune cells, and radiate them with UV light to make them invisible to the rest of the immune system before reinfusing them into the patient. This technique is used in patients with cutaneous T-cell lymphoma and some autoimmune diseases.
I also learned that you have to be careful with dosing methotrexate (a kind of chemotherapy) in patients in renal failure, with Down's syndrome, and patients who are "third-spacing." The first case is pretty simple; your kidneys filter out the toxic medicine after it circulates through the body. When the kidneys fail, the toxic stays around longer than usual and can do damage. With Down's patients, there is thought to be overexpression of some enzymes on the multiplied chromosome 21 that interfere with the drug metabolism resulting in higher levels of active drug in the blood stream.
The last one is a bit more complicated. "Third spacing" is when a patient is collecting unusual amounts of fluid outside of the two typical fluid "spaces" in the body (inside cells and in the blood stream). Instead the fluid pools in places like the abdominal cavity or the area around the lungs. But this fluid can still absorb chemicals like methotrexate, removing active drug from circulation, so the dosage required to get a typical effect is much higher. The problem is that we are usually also trying to eliminate this "third-spacing" so if you give large doses of the drug and then pull the unused drug back into the bloodstream from the extracellular spaces, then you've now overdosed the patient with medication they already had in their body.
WednesdayIL: Though ECP does stand for emergency contraceptive pill (as I learned in my OB/GYN rotation), it quickly became apparent that that is not what the pediatric oncologist was talking about in regards to treating a young boy's graft-vs-host disease. In this case, it turns out, ECP stands for extracorporeal photopheresis, a method of essentially cleaning the patient's white blood cells. The idea is to remove some of the patient's blood, separate out the immune cells, and radiate them with UV light to make them invisible to the rest of the immune system before reinfusing them into the patient. This technique is used in patients with cutaneous T-cell lymphoma and some autoimmune diseases.
I also learned that you have to be careful with dosing methotrexate (a kind of chemotherapy) in patients in renal failure, with Down's syndrome, and patients who are "third-spacing." The first case is pretty simple; your kidneys filter out the toxic medicine after it circulates through the body. When the kidneys fail, the toxic stays around longer than usual and can do damage. With Down's patients, there is thought to be overexpression of some enzymes on the multiplied chromosome 21 that interfere with the drug metabolism resulting in higher levels of active drug in the blood stream.
The last one is a bit more complicated. "Third spacing" is when a patient is collecting unusual amounts of fluid outside of the two typical fluid "spaces" in the body (inside cells and in the blood stream). Instead the fluid pools in places like the abdominal cavity or the area around the lungs. But this fluid can still absorb chemicals like methotrexate, removing active drug from circulation, so the dosage required to get a typical effect is much higher. The problem is that we are usually also trying to eliminate this "third-spacing" so if you give large doses of the drug and then pull the unused drug back into the bloodstream from the extracellular spaces, then you've now overdosed the patient with medication they already had in their body.
Tuesday, May 31, 2016
WILTIMS #479-82: Nephrology - Part I
Sorry for falling behind again! I have been taking notes in my little black book (spoiler-free example page on the right), and I'm hoping to do a crazy series of catch-up posts over the next day or so.A few weeks ago week I started my second two-week elective, nephrology. Taking a detour south from the lungs, I turned my currently myopic gaze to the kidneys. One of the reasons that nephrology was on my elective list was that kidney pathology is very physiology-heavy. You have to really know how the organ functions on a biochemical level to diagnose and treat kidney diseases. I like this connection with the basic sciences and the similar reliance on physiology in intensive care is part of why I'm leaning that way career-wise.
MIL: Dialysis machines measure the sodium concentration indirectly by measuring the conductivity of the dialysis solution. Pure water conducts electricity poorly, while salty water conducts very well. By measuring how conductive the water is, you can determine how salty the water must be. The predominant cation (positively charged molecule) in the dialysate broth is sodium, so conductivity ≈ saltiness ≈ sodium concentration. Who says high school chemistry was never useful!?
TuIL: Acute kidney injury (AKI) is classified by several systems. The older model is based around the RIFLE acronym,
WIL: Wednesday was our last class meeting of the year. We finally learned how we are going to sign up for our various fourth-year courses! Kind of... We subsequently had a lottery for our required courses and are still waiting for open enrollment for our electives. I also learned that there are over 20 people in my class planning on going into pediatrics, which is a huge increase over previous years. This made our required fourth-year course work difficult to schedule, because the simply aren't enough spots for everyone to do everything at convenient times.
ThIL: ACE inhibitor drugs decrease the filtration rate of the kidneys in the short-term. This is generally a bad thing for an already stressed kidney. But, in the long-term, the decrease in blood flow decreases the rate of glomerular damage. Think of it like an old car that is always parked under a bird-filled, pollen-generating tree. If you wash it every day, it gets clean, but eventually the paint is going to wear off. So wash it less often; that way it still gets cleaned regularly but, in the long-term, you avoid damaging your paint job.
Sunitinib is a chemo drug that has a side effect of dramatically increasing blood pressure. The effect is so consistent that blood pressure is often used as a marker for how well the chemo is working.
Many drugs break down in the body into active and inactive metabolites. If a patient has severe kidney disease, though, the inactive metabolites can build up to such high levels that they actually start causing side effects. Enough of anything is poisonous.
Wednesday, March 2, 2016
WILTIMS #438-42 : Medicine wrap-up
Ugh. Eight weeks of medicine was exhausting. It both seemed like it took forever, and yet it wasn't nearly enough time to master everything for the mini-board (ya know, 'cause it's all of medicine). Good thing I will get a chance to catch my breath on my next rotation: surgery! Did I say catch my breath? I meant never sleep again! Ah well. Sorry for the super-crazy delayed catch-up post. I'd say that I will be returning to a more regular schedule, but... surgery.
TwoWeeksAgoIL: The common antibiotic bactrim increases the creatinine level (a common marker for kidney dysfunction) without damaging the kidneys. So don't panic about a patient's worsening renal status immediately after starting bactrim.
TwoThursdaysAgoIL: The wait time for liver transplants varies dramatically by region within the United States. In parts of the deep south, like Georgia, the wait time can be as little as a month and a half, but in New York or California, the same patient could be waiting seven to eight months.
A patient must have been ignorant to their alcohol problem to be approved for a liver transplant for alcohol-related liver failure. If they had already been warned about their drinking, and continued to drink anyways, then we can't trust them with a precious organ that they might voluntarily destroy again. Newly diagnosed alcoholics must go through a rigorous sobriety program to earn their new liver.
Quote of the Day: "To do the lobectomy, you essentially burn your way through the liver. I think of it as Sherman's march to the sea..."
TwoFridaysAgoIL: Pes anserinus bursitis is the painful irritation of the insertion of three upper leg muscles into the medial aspect of the tibia. The name "pes anserinus" literally translates from latin as "goose's foot" because of the shape of the three muscles joining looks like the toes (do birds have toes? [shrugs] somebody call a veterinarian!) of a goose.
TwoMondaysAgoIL: ...how to draw an ABG and, more importantly, how it feels as a patient to have an ABG drawn. My classmate and I decided to fill some downtime by stabbing each other!!! We had both drawn venous blood (which is the normal blood draw) and we had both seen ABGs (arterial blood gases) drawn, but neither of us had drawn ABGs before. Arterial blood draws are known to be substantially more painful than normal venous blood due to the beefier architecture of the vessels. We didn't want to practice this potentially painful technique on patients. So we borrowed some supplies and successively and successfully drew ABG samples from each other's forearms. It didn't hurt at all as it was being done, but then a steady deep ache set in afterward that stuck with me for a few hours. Not pleasant. I will never frivolously order that test.
TwoTuesdaysAgoIL: An idioventricular rhythm can look like a backwards Mobitz type II 2nd degree heart block. It amazes me sometimes that things like that don't sound like gibberish anymore. So, an idioventricular rhythm is a heart rhythm seen after heart surgery where the ventricles are beating on their own without the guidance of the atria. Totally opposite of the norm, the ventricles are actually beating faster than the atria. On EKG, this can look weird and result in the few "p-waves" from the atria creep closer and closer to the QRS complexes or the ventricles. In a Mobitz type II heart block, the p-waves progressively pull away from the QRS complexes.
TwoWeeksAgoIL: The common antibiotic bactrim increases the creatinine level (a common marker for kidney dysfunction) without damaging the kidneys. So don't panic about a patient's worsening renal status immediately after starting bactrim.
TwoThursdaysAgoIL: The wait time for liver transplants varies dramatically by region within the United States. In parts of the deep south, like Georgia, the wait time can be as little as a month and a half, but in New York or California, the same patient could be waiting seven to eight months.
A patient must have been ignorant to their alcohol problem to be approved for a liver transplant for alcohol-related liver failure. If they had already been warned about their drinking, and continued to drink anyways, then we can't trust them with a precious organ that they might voluntarily destroy again. Newly diagnosed alcoholics must go through a rigorous sobriety program to earn their new liver.
Quote of the Day: "To do the lobectomy, you essentially burn your way through the liver. I think of it as Sherman's march to the sea..."
TwoFridaysAgoIL: Pes anserinus bursitis is the painful irritation of the insertion of three upper leg muscles into the medial aspect of the tibia. The name "pes anserinus" literally translates from latin as "goose's foot" because of the shape of the three muscles joining looks like the toes (do birds have toes? [shrugs] somebody call a veterinarian!) of a goose.
TwoMondaysAgoIL: ...how to draw an ABG and, more importantly, how it feels as a patient to have an ABG drawn. My classmate and I decided to fill some downtime by stabbing each other!!! We had both drawn venous blood (which is the normal blood draw) and we had both seen ABGs (arterial blood gases) drawn, but neither of us had drawn ABGs before. Arterial blood draws are known to be substantially more painful than normal venous blood due to the beefier architecture of the vessels. We didn't want to practice this potentially painful technique on patients. So we borrowed some supplies and successively and successfully drew ABG samples from each other's forearms. It didn't hurt at all as it was being done, but then a steady deep ache set in afterward that stuck with me for a few hours. Not pleasant. I will never frivolously order that test.
TwoTuesdaysAgoIL: An idioventricular rhythm can look like a backwards Mobitz type II 2nd degree heart block. It amazes me sometimes that things like that don't sound like gibberish anymore. So, an idioventricular rhythm is a heart rhythm seen after heart surgery where the ventricles are beating on their own without the guidance of the atria. Totally opposite of the norm, the ventricles are actually beating faster than the atria. On EKG, this can look weird and result in the few "p-waves" from the atria creep closer and closer to the QRS complexes or the ventricles. In a Mobitz type II heart block, the p-waves progressively pull away from the QRS complexes.
Tuesday, February 16, 2016
WILTIMS #435-7: Experimenting
On Thursday, I was given a blessed reprieve from the torture of geriatric clinic so that I could present a poster at our school's Medical Student Research Forum. The poster was displaying an incredibly deceiving selection of information on the research that I helped gather as one of the leaders of the Cancer Education Awareness Program club. The data were accurate but of extremely narrow usefulness. I have trash-talked this research for so long, it was hard to sell it to reviewers and interested passersby with a straight face.
After having two reviewers hear us out, my presentation partner and I were fairly confident that we weren't winning any awards. Still, just to be sure, I stayed around through the big oral presentations to await the official losers' notice. The presentations were surprisingly good. The first guy's research had made national headlines when his team mapped the NYC subway biome and found plague and anthrax among the other more benign pathogens.
ThursdayIL: Actually, they don't think they found anthrax and plague. Nearly half of the life they found was unidentifiable by current techniques and it's more likely that the weird ones they did find were actually just as of yet unknown close relatives of those oddball bugs.
Friday, I was back at the hospital for my last day in geriatric clinic. The most interesting patient encounter of the day was actually due to a patient's daughter who had psychiatric problems of her own and yelled at our team for "experimenting" on her mildly demented father. All medications have potential adverse reactions and we can't (yet) predict which patients which react poorly. This patient may have had a reaction to a normally very safe medication we recently started... or the daughter may have altered his other psychiatric medications without consulting us. It was hard to tell who was actually "experimenting."
FridayIL: Frailty is an actual clinical diagnosis. Though it is not a true pathology, if a patient meets the (extremely specific) criteria then they statistically have significantly increased mortality from all causes.
Today I started with a new team on the inpatient wards, with whom I will slog out the remaining week and a half of this rotation (yikes!). Due to some weirdness with scheduling we practically had our whole previous team together for the day, so it was like a surprise reunion. I miss that team (sniff!).
TIL: Isothenuria is when the urine is osmotically similar to blood (neither concentrated nor dilute). This can be totally normal or a sign of renal failure depending on the broader clinical picture.
If a patient with a PMH (past medical history) of SCD (sickle cell disease) presents to the ER with symptoms that can be explained by a sickle cell crisis, check the reticulocyte count. The retic count represents the release of immature blood cells into the bloodstream and is a measure of hemolysis (blood cell death). The higher the count, the worse the hemolysis and the more severe the sickle cell crisis.
Pingueculae are a slight variation on pterygia, both lesions of the conjunctiva of the eye. Whereas a pterygium is seen more commonly on the nose-side of the eye and grow out toward the pupil, a pinguecula is usually seen on the ear-side of the eye and grows thicker, not moving in any direction.
After having two reviewers hear us out, my presentation partner and I were fairly confident that we weren't winning any awards. Still, just to be sure, I stayed around through the big oral presentations to await the official losers' notice. The presentations were surprisingly good. The first guy's research had made national headlines when his team mapped the NYC subway biome and found plague and anthrax among the other more benign pathogens.
ThursdayIL: Actually, they don't think they found anthrax and plague. Nearly half of the life they found was unidentifiable by current techniques and it's more likely that the weird ones they did find were actually just as of yet unknown close relatives of those oddball bugs.
Friday, I was back at the hospital for my last day in geriatric clinic. The most interesting patient encounter of the day was actually due to a patient's daughter who had psychiatric problems of her own and yelled at our team for "experimenting" on her mildly demented father. All medications have potential adverse reactions and we can't (yet) predict which patients which react poorly. This patient may have had a reaction to a normally very safe medication we recently started... or the daughter may have altered his other psychiatric medications without consulting us. It was hard to tell who was actually "experimenting."
FridayIL: Frailty is an actual clinical diagnosis. Though it is not a true pathology, if a patient meets the (extremely specific) criteria then they statistically have significantly increased mortality from all causes.
Today I started with a new team on the inpatient wards, with whom I will slog out the remaining week and a half of this rotation (yikes!). Due to some weirdness with scheduling we practically had our whole previous team together for the day, so it was like a surprise reunion. I miss that team (sniff!).
TIL: Isothenuria is when the urine is osmotically similar to blood (neither concentrated nor dilute). This can be totally normal or a sign of renal failure depending on the broader clinical picture.
If a patient with a PMH (past medical history) of SCD (sickle cell disease) presents to the ER with symptoms that can be explained by a sickle cell crisis, check the reticulocyte count. The retic count represents the release of immature blood cells into the bloodstream and is a measure of hemolysis (blood cell death). The higher the count, the worse the hemolysis and the more severe the sickle cell crisis.
Pingueculae are a slight variation on pterygia, both lesions of the conjunctiva of the eye. Whereas a pterygium is seen more commonly on the nose-side of the eye and grow out toward the pupil, a pinguecula is usually seen on the ear-side of the eye and grows thicker, not moving in any direction.
Tuesday, February 2, 2016
WILTIMS #428: Needing Beers to get through geriatrics
Last Tuesday I had a really good day. Today was less so. As much of the miserableness involved people who control my grade and my little blog is technically a public forum, I will just leave it at that.
This week I started my two week stay in the hospital's geriatric clinic. Not my particular cup of tea, but it should be survivable for the short duration. I had an interesting experience today looking back through the chart of a very elderly patient. Currently about 85 years old with several serious health conditions, she needed of a good deal of assistance with her daily activities. As with any patient, I read-up on her recent admissions and notes from the doctors who had taken care of her. I learned a good deal about her medical history, but very little about her personal life - her story.
So then I dug into the social workers' notes. These provide great details about a person's living situation. I was surprised to find electronic records going back over ten years to when the patient was about 70 years old. And suddenly I realized that I had the documented history of one woman's journey into old age and frailty. each successive note showed how a heart condition or fall changed what she was able to do and how she was able to live.
I realize that the sorts of records have always existed in some form, but with the adoption of electronic medical records, it will become so much easier to essentially read the (very dryly written) story of someone's life through their interactions with the medical field.
TIL: AICD stands for artificial internal cardioverter/defibrillator.
The Beers Criteria is a list of drugs that should be used cautiously in the geriatric population. When it was first created in 1991 by Dr. Beers, it was a very simple, one-page tool to help prevent needlessly dangerous prescriptions. The most recent version is a dozen pages of very specific guidelines. Not sure if that's really serving the same purpose anymore...
While researching the Beers criteria, I learned what a non-anti-infective medication is. I'll let you read that one more time: non-anti-infective medication. What? Despite how it might seem, the negatives do not cancel out, which would make these simply infective medications. Actually these are medications other than those used to kill or weaken infectious pathogens such a bacteria, viruses, fungi, and parasites.
Endoscopic ultrasound is a nice alternative to MRCP for imaging choledocolithiasis.
Whereas gallbladder pain radiates to the chest and shoulder, the common bile duct radiates to the flank and back.
This week I started my two week stay in the hospital's geriatric clinic. Not my particular cup of tea, but it should be survivable for the short duration. I had an interesting experience today looking back through the chart of a very elderly patient. Currently about 85 years old with several serious health conditions, she needed of a good deal of assistance with her daily activities. As with any patient, I read-up on her recent admissions and notes from the doctors who had taken care of her. I learned a good deal about her medical history, but very little about her personal life - her story.
So then I dug into the social workers' notes. These provide great details about a person's living situation. I was surprised to find electronic records going back over ten years to when the patient was about 70 years old. And suddenly I realized that I had the documented history of one woman's journey into old age and frailty. each successive note showed how a heart condition or fall changed what she was able to do and how she was able to live.
I realize that the sorts of records have always existed in some form, but with the adoption of electronic medical records, it will become so much easier to essentially read the (very dryly written) story of someone's life through their interactions with the medical field.
TIL: AICD stands for artificial internal cardioverter/defibrillator.
The Beers Criteria is a list of drugs that should be used cautiously in the geriatric population. When it was first created in 1991 by Dr. Beers, it was a very simple, one-page tool to help prevent needlessly dangerous prescriptions. The most recent version is a dozen pages of very specific guidelines. Not sure if that's really serving the same purpose anymore...
While researching the Beers criteria, I learned what a non-anti-infective medication is. I'll let you read that one more time: non-anti-infective medication. What? Despite how it might seem, the negatives do not cancel out, which would make these simply infective medications. Actually these are medications other than those used to kill or weaken infectious pathogens such a bacteria, viruses, fungi, and parasites.
Endoscopic ultrasound is a nice alternative to MRCP for imaging choledocolithiasis.
Whereas gallbladder pain radiates to the chest and shoulder, the common bile duct radiates to the flank and back.
Sunday, January 31, 2016
WILTIMS #422-6: End of January catch-up post
Tuesday was a good day. As I assume is the case with most jobs (not that this is quite my job, yet), most days are OK, some suck, and a precious few validate all the work I do the rest of the time. On this medicine rotation I've had a surprising amount of moments that remind me why I love medicine (the royal medicine, not just internal medicine). Tuesday just had a few more than normal and it felt nice.
I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!
Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).
Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.
MondayIL: BIBEMS is an acronym for brought in by emergency medical services.
TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.
WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.
ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.
FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:
If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.
*Patient details changed for anonymity*
I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!
Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).
Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.
MondayIL: BIBEMS is an acronym for brought in by emergency medical services.
TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.
WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.
ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.
FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:
If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.
*Patient details changed for anonymity*
Saturday, October 24, 2015
WILTIMS #371: Lessons for my future self
One of the skills that we are supposed to be honing during our clinical years is the ability to understand and thrive in a complex health care institution or, put more succinctly, to brave the bureaucracy. Med students, being somewhat intelligent, are generally capable of figuring out how things work in whatever setting we are thrown into. That includes straightforward things like how to use the electronic chart or the procedure for requesting blood from the blood bank, and more subtle things like who to address by first name, what work is supposed to be done by who, or where it's best to stand in a crowd based on a need-to-know hierarchy.
One of the more specific areas of this general category of learning is not explicitly part of our curriculum. Often subliminally, we are learning how to and how not to teach. Being at the very bottom of the totem poll, we have no one below us to teach yet. But in nearly every interaction with the fourth-years, residents, and attendings above us, we are finding out what styles of instruction are most and least effective.
It's actually remarkable that in a field where after a couple years you are taught, not by dedicated instructors, but by the students themselves that are ahead of you in the educational tract, we are never extensively taught to teach. Because of this, some people are great at it, others learn to be better, and still some remain stubbornly oblivious to their daily missteps. So, in what seems like a surprisingly mature response, some of my classmates and I have come to look at each poor interaction with our superiors as an opportunity to note for our future selves how we can try to consciously avoid the same pitfalls when we are in our superiors' shoes.
Here are some of the takeaways I can think of at the moment:
One of the more specific areas of this general category of learning is not explicitly part of our curriculum. Often subliminally, we are learning how to and how not to teach. Being at the very bottom of the totem poll, we have no one below us to teach yet. But in nearly every interaction with the fourth-years, residents, and attendings above us, we are finding out what styles of instruction are most and least effective.
It's actually remarkable that in a field where after a couple years you are taught, not by dedicated instructors, but by the students themselves that are ahead of you in the educational tract, we are never extensively taught to teach. Because of this, some people are great at it, others learn to be better, and still some remain stubbornly oblivious to their daily missteps. So, in what seems like a surprisingly mature response, some of my classmates and I have come to look at each poor interaction with our superiors as an opportunity to note for our future selves how we can try to consciously avoid the same pitfalls when we are in our superiors' shoes.
Here are some of the takeaways I can think of at the moment:
- Communicate better
- Be explicit- Until proven otherwise, assume that your mentee has no idea who or what you are referring to when you use pronouns or acronyms. "Go down to Dr. Mumble's office and ask her what the EP3!TX value is," is just asking to get a blank stare back from the person.
- Keep everyone in the loop - If the only interesting thing a medical student will get to do today is a surgery and that surgery has been moved up, make sure to let them know.
- Be efficient/respectful with other people's time
- Try not to make someone wait an hour for something that requires 30 seconds of your time.
- If you assign something like a presentation for a student to work on, actually bother to listen to them present it, even if briefly.
- Be nice
- If someone doesn't know the answer to your question, don't judge or berate them. Maybe ask them to look it up for tomorrow.
- Fill out forms
- Remember how important and stressful all the stupid forms that med schools make you fill out are to the students. Just because they're dumb, it doesn't mean they're not a major area of anxiety for your mentee.
- Show/explain everything
- Anything is more interesting than standing in the corner, wishing for something to do. Bring your student everywhere with you and monologue as much as possible to show them why you're doing whatever you're doing. It's much easier to learn when you're A) in the room and B) not guessing in silence about what's happening.
- Be enthusiastic
- At least occasionally, try to show why you chose to go into your field and kindle some excitement in your mentee. Being jaded is poisonous to an enjoyable learning atmosphere.
Monday, October 19, 2015
WILTIMS #367: 24 hour call - Wrap-up
Continued from Part 3...
20:14 - That's it folks! I'm a little sad to admit it, but my big 24 hour call turned out to actually be a 14 hour call. I know people that have done more than that on what was supposed to be a 12 hour shift. But one of the cardinal rules of medical school is, when someone tells you to leave, leave. You will not get brownie points for staying and everyone will be happier if you go sleep/eat/study and come back rejuvenated the next day.
But since this day was supposed to be a transition day to my upcoming week of night shifts, I still need to stay up as long as I can to disrupt my sleep schedule.
23:16 - Well, the Mets helped a little, but I'm pooped. Here's hoping some Netflix and bright light will keep me going!
04:30 - Nope! I did enjoy that first three and a half minutes of Batman Begins, but even sitting in an awkward position with all the lights on and sipping a soda, I nodded off immediately. I'm going to go sleep in my bed for a bit now and hopefully sleep and nap through the rest of the day. Tonight I get one more go at staying up before my night shift on Tuesday.
TIL: Whereas emergency high blood pressure levels in an adult are over 180 systolic, in pregnant women it's only 160.
There are several pharmacological interventions that doctors can use to either prolong a preterm pregnancy or to improve the outcome if the baby is born premature. Giving magnesium sulfate to a woman with signs of premature labor is neuroprotective to the
Fetal heart rate variability can fall into several descriptive categories:
absent: flatlineFinally, a health fetus has periodic elevations in heart rate called accelerations. before 32 weeks, you want to see two accelerations of 10 bpm over the baseline for 10 seconds each over any 20 minute period. From 32 weeks on, you want two of 15 bpm of 15 sec in 20 minutes.
minimal: 1-4 beats per minute (bpm) of variability
moderate: 5-25 bpm
marked: >25 bpm
*In obstetrics, weeks are denoted as nx where n is the number of weeks and x is the number of additional days. So 26 weeks and 5 days is 265 weeks.
Wednesday, August 5, 2015
WILTIMS #328: ♪♫ She's a maniac, maniac! ♪♫
Manic patients are a pain in the butt. They're no more annoying to treat than, say, people with schizophrenia, but they are a pain to keep on the unit with the other patients. If you have a group of sick people who are confined to an inpatient psych ward to provide a calm, healing environment, having a patient (or two!) that physically can't stop talking and pestering and advising and touching and... It get's on both the patients' and staff's nerves. Sometimes half the battle for the nursing staff is just keeping the peace between patients.
TIL: When transitioning from oral dosing to long-acting injections of paliperidone (Invega®), an atypical antipsychotic, you start with a loading dose of 234mg, then on day 8 you give a 156mg booster, and then on day 36 you start the regular monthly dose which can vary from 78 to 234mg.
In a previous post, I mentioned that lithium gets a bad rap as a dangerous drug during pregnancy. At the time, I mentioned that untreated bipolar is more dangerous than the tiny risk of an obscure birth defect associated with lithium use. This is still true, but additionally, all the other mood stabilizing drugs we use to treat bipolar disorder cause other birth defects and at greater rates. Valproic acid (Depakote®) and carbamazepine cause neural tube defects like spina bifida in 3-5% and 1% of pregnancies, respectively. By comparison, studies have shown lithium's Ebstein anomaly happens only 0.05-0.005% of the time.
TIL: When transitioning from oral dosing to long-acting injections of paliperidone (Invega®), an atypical antipsychotic, you start with a loading dose of 234mg, then on day 8 you give a 156mg booster, and then on day 36 you start the regular monthly dose which can vary from 78 to 234mg.
In a previous post, I mentioned that lithium gets a bad rap as a dangerous drug during pregnancy. At the time, I mentioned that untreated bipolar is more dangerous than the tiny risk of an obscure birth defect associated with lithium use. This is still true, but additionally, all the other mood stabilizing drugs we use to treat bipolar disorder cause other birth defects and at greater rates. Valproic acid (Depakote®) and carbamazepine cause neural tube defects like spina bifida in 3-5% and 1% of pregnancies, respectively. By comparison, studies have shown lithium's Ebstein anomaly happens only 0.05-0.005% of the time.
Wednesday, July 29, 2015
WILTIMS #324: Pepperoni with a side of paranoia
This afternoon had a beautifully comedic moment, but it was a weird situation so bear with me as I set the stage.
Throughout the day, the patients have activities that they can participate in like music therapy, art expression, board games, etc. I had finished my duties for the day, so to take a break from studying, I decided to sit in on the session and observe the patient's in this setting. The moment I walked into the room, something seemed off.
This afternoon's activity leader was a man I had never met and who, at first, I seriously thought must have been a newly admitted patient. His topic of choice seemed to be poorly informed geopolitical theory and the inevitability of nuclear war - topics I expect from the schizophrenic patients, not the people helping treat them. I love me some good ol' geopolitical debates, but talking about the coming nuclear apocalypse and World War III in a room with paranoid veterans who already have similar delusions just seems like a bad idea. Perhaps he was redirecting an inappropriate comment by a patient, I thought. A few minute of listening to the conversation quickly showed that the more coherent patients where actually giving more level-headed opinions and attempting to steer the topic back to a happier place. Some of them had surprisingly reasonable points.
There are several nurses in the area as well and we were all silently making eye contact conveying something to the effect of, This is weird, right? One nurse valiantly tried to turn the conversation into something more appropriate. "The idea," she said, "that we as a country might want to take care of our own needs before worrying about others', reminds me of our own personal basic needs. I need to take care of myself before I can take care of anyone else. What other basic needs do we have?" It was superb, but futile. A few minutes later the guest activity leader was once again talking about Iran already having a nuke and how we should have bombed China in WWII. A second nurse eventually pulled the man out of the room for a moment to talk with him about the topic, but he came back with the same enthusiasm.
The people that finally put an end to this bizarre situation were actually the worst-off patients in the room. One patient wandered over to where the man was sitting and started to talk over him to us about absolute gibberish. Another offered up his opinion about Iran by talking about eating pizza with a friend. It was beautiful. It was like when a small child says something totally right, but completely inappropriate - like yelling "Mommy, that man smells really bad!" when walking past a smoker. It's inappropriate, but you almost want to laugh and give the kid a high-five, even though they have no idea why what they did was wrong or why you enjoyed it so much.
I wanted laugh and continue the pizza topic, but instead quietly smiled as the activity leader got flustered and decided he was done for the day. Good job guys. I'm proud of you.
TIL: Research has hinted that a large proportion of the patients with comorbid schizophrenia and obsessive-compulsive symptoms may have developed the OC symptoms as a side effect of treatment with the particularly nasty antipsychotic drug, clozapine.
Throughout the day, the patients have activities that they can participate in like music therapy, art expression, board games, etc. I had finished my duties for the day, so to take a break from studying, I decided to sit in on the session and observe the patient's in this setting. The moment I walked into the room, something seemed off.
This afternoon's activity leader was a man I had never met and who, at first, I seriously thought must have been a newly admitted patient. His topic of choice seemed to be poorly informed geopolitical theory and the inevitability of nuclear war - topics I expect from the schizophrenic patients, not the people helping treat them. I love me some good ol' geopolitical debates, but talking about the coming nuclear apocalypse and World War III in a room with paranoid veterans who already have similar delusions just seems like a bad idea. Perhaps he was redirecting an inappropriate comment by a patient, I thought. A few minute of listening to the conversation quickly showed that the more coherent patients where actually giving more level-headed opinions and attempting to steer the topic back to a happier place. Some of them had surprisingly reasonable points.
There are several nurses in the area as well and we were all silently making eye contact conveying something to the effect of, This is weird, right? One nurse valiantly tried to turn the conversation into something more appropriate. "The idea," she said, "that we as a country might want to take care of our own needs before worrying about others', reminds me of our own personal basic needs. I need to take care of myself before I can take care of anyone else. What other basic needs do we have?" It was superb, but futile. A few minutes later the guest activity leader was once again talking about Iran already having a nuke and how we should have bombed China in WWII. A second nurse eventually pulled the man out of the room for a moment to talk with him about the topic, but he came back with the same enthusiasm.
The people that finally put an end to this bizarre situation were actually the worst-off patients in the room. One patient wandered over to where the man was sitting and started to talk over him to us about absolute gibberish. Another offered up his opinion about Iran by talking about eating pizza with a friend. It was beautiful. It was like when a small child says something totally right, but completely inappropriate - like yelling "Mommy, that man smells really bad!" when walking past a smoker. It's inappropriate, but you almost want to laugh and give the kid a high-five, even though they have no idea why what they did was wrong or why you enjoyed it so much.
I wanted laugh and continue the pizza topic, but instead quietly smiled as the activity leader got flustered and decided he was done for the day. Good job guys. I'm proud of you.
TIL: Research has hinted that a large proportion of the patients with comorbid schizophrenia and obsessive-compulsive symptoms may have developed the OC symptoms as a side effect of treatment with the particularly nasty antipsychotic drug, clozapine.
Tuesday, July 28, 2015
WILTIMS #323: To the Wayback Machine!
Today was fun. I got to leave my clerkship early to give a presentation to the incoming first year class during their orientation. Looking all the way back to when I was in their seats is a bit easier for me than most thanks to this blog. Here is the post from my Tuesday of orientation week. I think it's especially fitting that the group I was presenting on behalf of today did not exist when I was an incoming first year. Our school is always evolving and attempting to make things better. I wonder what changes this new class inspires in the years to come...
TIL: One of the several protocols for tapering a patient down from severe alcohol withdrawal is seen below. Since alcohol's sedative effects act primarily through GABA receptors, instead of giving them more alcohol in the hospital (which would be bad due to all of alcohol's other effects) we supplement with another GABA agonist, usually in the benzodiazepine class of drugs. Below is what the actual order would look like in a patient's chart. The ordering physician would also check on the patient periodically to see if the withdrawal symptoms are being appropriately managed. If not, then the orders might be altered to add another day to give the patient's body time to begin detoxifying itself.
TIL: One of the several protocols for tapering a patient down from severe alcohol withdrawal is seen below. Since alcohol's sedative effects act primarily through GABA receptors, instead of giving them more alcohol in the hospital (which would be bad due to all of alcohol's other effects) we supplement with another GABA agonist, usually in the benzodiazepine class of drugs. Below is what the actual order would look like in a patient's chart. The ordering physician would also check on the patient periodically to see if the withdrawal symptoms are being appropriately managed. If not, then the orders might be altered to add another day to give the patient's body time to begin detoxifying itself.
50mg chlordiazepoxide PO Q6h on day 1Legend: mg = milligrams, PO = by mouth, QXh = every X hours, BID = twice daily, QAM = every morning, prn = as needed, SBP = systolic blood pressure, DBP, = diastolic blood pressure, HR = heart rate, pt = patient
50mg chlordiazepoxide PO Q8h on day 2
50mg chlordiazepoxide PO BID on day 3
25mg chlordiazepoxide PO BID on day 4
25mg chlordiazepoxide PO QAM on day 5
25mg chlordiazepoxide PO Q4h prn breakthrough anxiety, max 3 doses/day
Vitals Q4h
If SBP < 100 or DBP < 60 or HR > 100 or pt displays marked sedation HOLD MEDS
Tuesday, July 14, 2015
WILTIMS #313: Code 66
Every hospital I've ever worked, volunteered or studied in has had a totally different set of emergency codes. Usually there are colors (e.g code blue, code red, code brown) mixed with other random codes that inexplicably ruin the theme (e.g. code triage, code zebra). You'd think some of the well known ones like code blue would stay consistent, but some hospitals just need to be different, so you have to relearn them at every facility you find yourself at.
My current hospital has two codes that I've been told to know: code 66 and code 99. Why you would pick the only superimposable numbers is beyond me. In any case, code 66 refers to a psychiatric emergency while a code 99 refers to a medical emergency. Exactly a week ago, I saw my first (false alarm) code 99. After the code was called over the campus-wide intercom, an ambulance, paramedics and eventually two doctors showed up to make sure the patient was alright medically (he was).
Today I saw my first code 66. A patient was not responding to the nurses' calls to calm down and he would not let them give him a sedating medication. Once the code was called, myself and all the psychiatric staff rushed out of the nearby offices to the area the patient was in, in case we were needed before the real help arrived. And boy did it arrive. A nurse and doctor from another floor as well as six fully armed police officers arrived to help subdue the patient until we could administer the sedative. Given the modest danger of being on a locked ward with some agitated, very physically powerful patients, it's nice to know that a whole lot of help is just a call away.
TIL: When giving a sedative in an emergency situation as mentioned above, remember to be patient and wait for the medication to take effect. It can be easy to succumbed to panicky pressure to repeatedly inject the patient until you see results, but you must remember that these drugs take time to take effect. Doubling or tripling the dose can quickly over-correct the agitation and even kill the patient.
B52 or 5-2-50 is a common concoction of medications used at an emergency sedative and antipsychotic. in each of the two names, the 5 and 2 represent 5 mg of haldol and 2 mg of lorazepam, respectively. The B and 50 refer to 50 mg of diphenhydramine, aka Benadryl.
In 2004, the FDA issued a black box warning on antidepressants that warned of an increased risk of suicide in children. Though it seems counterintuitive, the data showed that for certain patients at a specific point in their treatment, they go from being suicidal and apathetic, to still being suicidal but having enough energy to commit the act. If the kids make it through this period, they're in the clear, but the FDA thought parents should be warned. In 2005, more children committed suicide than any year on record - not because of the antidepressants, but because a large percentage parents misunderstood the tiny risk and refused to let their children take antidepressants at all.
The three classic treatments for refractory suicidal ideation are clozapine, lithium, and electroconvulsive therapy (ECT). ECT has gained a bad stigma, for good reason, as it was one of the treatments of choice during the dark ages of mid-20th century psychiatry. Though, most of the old uses had little supporting evidence, a few conditions actually respond very well to shock therapy. The big difference today is that we actually use anesthetics so that the brain is effectively given a seizure as a sort of electrical reset without disturbing the patient in any conscious way.
My current hospital has two codes that I've been told to know: code 66 and code 99. Why you would pick the only superimposable numbers is beyond me. In any case, code 66 refers to a psychiatric emergency while a code 99 refers to a medical emergency. Exactly a week ago, I saw my first (false alarm) code 99. After the code was called over the campus-wide intercom, an ambulance, paramedics and eventually two doctors showed up to make sure the patient was alright medically (he was).
Today I saw my first code 66. A patient was not responding to the nurses' calls to calm down and he would not let them give him a sedating medication. Once the code was called, myself and all the psychiatric staff rushed out of the nearby offices to the area the patient was in, in case we were needed before the real help arrived. And boy did it arrive. A nurse and doctor from another floor as well as six fully armed police officers arrived to help subdue the patient until we could administer the sedative. Given the modest danger of being on a locked ward with some agitated, very physically powerful patients, it's nice to know that a whole lot of help is just a call away.
TIL: When giving a sedative in an emergency situation as mentioned above, remember to be patient and wait for the medication to take effect. It can be easy to succumbed to panicky pressure to repeatedly inject the patient until you see results, but you must remember that these drugs take time to take effect. Doubling or tripling the dose can quickly over-correct the agitation and even kill the patient.
B52 or 5-2-50 is a common concoction of medications used at an emergency sedative and antipsychotic. in each of the two names, the 5 and 2 represent 5 mg of haldol and 2 mg of lorazepam, respectively. The B and 50 refer to 50 mg of diphenhydramine, aka Benadryl.
In 2004, the FDA issued a black box warning on antidepressants that warned of an increased risk of suicide in children. Though it seems counterintuitive, the data showed that for certain patients at a specific point in their treatment, they go from being suicidal and apathetic, to still being suicidal but having enough energy to commit the act. If the kids make it through this period, they're in the clear, but the FDA thought parents should be warned. In 2005, more children committed suicide than any year on record - not because of the antidepressants, but because a large percentage parents misunderstood the tiny risk and refused to let their children take antidepressants at all.
The three classic treatments for refractory suicidal ideation are clozapine, lithium, and electroconvulsive therapy (ECT). ECT has gained a bad stigma, for good reason, as it was one of the treatments of choice during the dark ages of mid-20th century psychiatry. Though, most of the old uses had little supporting evidence, a few conditions actually respond very well to shock therapy. The big difference today is that we actually use anesthetics so that the brain is effectively given a seizure as a sort of electrical reset without disturbing the patient in any conscious way.
Monday, July 13, 2015
WILTIMS #312: I'll do it in a GIFfy!
I am a PRN of lorazepam! I'm taking this as a compliment from my supervising psychiatrist, but I bet it needs more explanation before most of you will see why.
My supervisor asked me to interview a new patient near the end of the day. We had heard that he was a little upset about being admitted against his will, which seems understandable. My supervisor thought I could handle him (but it would probably be best to keep around the nurse assigned to watch him). Brimming with confidence, I set out to find the patient.
About 30 seconds later, having found the nursing station abandoned, no staff members in sight, and realizing I have no idea who this patient is, what he looks like, or where to find him, my confidence returned to Toby Turtle levels. After awkwardly walking in circles enough that schizophrenic patients came over and asked if I was ok, I finally figured out that a nurse was already talking to the new patient in a private room.
Disappointed and dejected, I shuffled back to my supervisor and explained that the patient was busy talking to a nurse and was unlikely to be free or willing to talk with me in the near future. He listened and shrugged. He said (paraphrasing), "Oh, well that's ok. I was really just going to use you to calm him down a bit and if he's already isolated and talking to someone, that's probably fine. You just have such a soothing presence; you're like a PRN of lorazepam." [Translation: you're like an as-needed anti-anxiety drug] - I think this is a good thing. Also, I know that a few of my readers (e.g. my siblings) would take issue with this description of me.
TIL: The major cause of death for patients who die from complications of eating disorders is hypokalemia (low potassium).
It is important to remember that when psychiatric patients decide to stop taking their medications, they usually stop taking all of their medications. Thus it is not uncommon to see patients with decompensated diabetes, sudden hypothyroidism, or severe high blood pressure.
Though we're warned when studying for boards about the rare heart birth defect caused by lithium use during pregnancy, called Ebstein's anomaly, in real life the risk is so much lower than the risk of untreated bipolar disorder, especially with a suddenly discovered, unplanned pregnancy, that often lithium is actually the best choice for treatment.
Disappointed and dejected, I shuffled back to my supervisor and explained that the patient was busy talking to a nurse and was unlikely to be free or willing to talk with me in the near future. He listened and shrugged. He said (paraphrasing), "Oh, well that's ok. I was really just going to use you to calm him down a bit and if he's already isolated and talking to someone, that's probably fine. You just have such a soothing presence; you're like a PRN of lorazepam." [Translation: you're like an as-needed anti-anxiety drug] - I think this is a good thing. Also, I know that a few of my readers (e.g. my siblings) would take issue with this description of me.TIL: The major cause of death for patients who die from complications of eating disorders is hypokalemia (low potassium).
It is important to remember that when psychiatric patients decide to stop taking their medications, they usually stop taking all of their medications. Thus it is not uncommon to see patients with decompensated diabetes, sudden hypothyroidism, or severe high blood pressure.
Though we're warned when studying for boards about the rare heart birth defect caused by lithium use during pregnancy, called Ebstein's anomaly, in real life the risk is so much lower than the risk of untreated bipolar disorder, especially with a suddenly discovered, unplanned pregnancy, that often lithium is actually the best choice for treatment.
Thursday, July 9, 2015
WILTIMS #310: Sometimes, just ask
I actually did something productive! I was joking on Tuesday that my only helpful attribute was being male so that I could check the bathrooms for the missing veteran (who has since been found BTW). Well today, I finally did something useful in my capacity as a medical student. It was reported by the nursing staff in morning report that a normally compliant patient refused to take his medication last night. This came as a bit of a disappointment to the medical staff as we had had a very pleasant meeting with him the previous day about reducing that medication but in a safe, controlled way. As my supervising doctor was very busy this morning with some new admissions, I was given the task of interviewing the handful of his patients that I'm familiar with, one of the goals being to figure out why the patient had refused his meds. A common reason on a psych ward is a paranoid delusion that the meds are doing something other than what the doctors/nurses say they're doing.
The answer turned out to be very simple. I asked him why he refused the medication and he very reasonably explained that the nurses were giving the medication later at night than the patient was comfortable with. All it took was someone (like me!) to ask and for the doctor to schedule to medication at the evening dispensary time instead of the night one and we were good to go.
I know this is a tiny action and the mystery would definitely have been solved by someone else if I weren't there, but it still felt nice to be actively involved in improving a patient's care.
This case actually has another interesting point. The medication was at the center of our efforts to pin down what was ailing the patient. He had been on this med for years, but we are concerned that it may be treating a condition he doesn't have. So we began weaning down the dose to see if one of three things happens:
- The patient gets worse, showing that the meds were doing something right
- The patient gets better, showing that the side effects were severe
- Nothing happens, showing that the medication wasn't doing anything and should be discontinued
TIL: Don't prescribe benzodiazepines to recovering opiate abusers as both drug classes depress respiratory function and if the patient falls off the wagon, they risk life threatening drug interactions.
Double depression is a term for when a patient with dysthymia (chronic atypical depression) develops a major depressive episode as well.
Tuesday, July 7, 2015
WILTIMS #308: The VA
So out of the ~25 people in my class doing their psychiatry clerkship right now, I am the only one at a Veteran Affairs (VA) hospital. I wasn't terribly worried about it being a VA, but being alone on my first clerkship seemed a daunting experience. After two days at the hospital, I think my division of anxiety was spot on.
Everyone I have interacted with at the VA has been wonderful. It might just be culture shock after driving 45 minutes north from my apartment in the Bronx, but I swear every person you walk past in the halls or on the sidewalk makes eye contact and says something to the effect of "Good morning" or "How's it going?" or, at the very least, gives a smile and a nod. If you tried any of that in my neighborhood you would, at best, get weird looks and, at worst, get stabbed*.
Today a veteran with relatively loose restrictions on staying in the building ran away. The psychiatrist I was following was frustrated, bordering on irate throughout the whole ordeal. At first, I was a little put off by the doctor's emotional response and shortness with the police officers that showed up to get information on the missing person. Then I recognised this reaction. It's the reaction of a family member when someone close to them does something stupid and dangerous. It's the "if he survives. I'm gonna kill him" sort of mentality. Everyone at this campus cares about the patients as if they were family. Sometimes family disappoints you or makes you angry, but that doesn't mean you don't care. And when your patient is like family, you can't help but care about them as you care for them.
TIL: A general rule for psychoactive medications is that you have to wait ~5 days for the blood levels to level out before doing a blood test to see how the patient metabolizes the medication. And when you do draw the blood level, it should be as close as possible to halfway between doses (so for a once a day drug, wait 12 hours after the last dose).
If you're ever a psych patient and you have a sarcastic sense of humor, you may want to lay off the jokes during your interactions with the staff. The whole way that sarcasm works is by saying something that is out of character or opposite of the obvious reaction. A sane person might say the same thing sarcastically that a psychotic person might say seriously. You do not want a doctor/nurse to rely on tone of voice to understand which you mean.
The treatment for lithium overdose is emergency dialysis.
*Jenni would like me to point out that this is a bit hyperbolic as our neighborhood is not that bad.
Everyone I have interacted with at the VA has been wonderful. It might just be culture shock after driving 45 minutes north from my apartment in the Bronx, but I swear every person you walk past in the halls or on the sidewalk makes eye contact and says something to the effect of "Good morning" or "How's it going?" or, at the very least, gives a smile and a nod. If you tried any of that in my neighborhood you would, at best, get weird looks and, at worst, get stabbed*.
Today a veteran with relatively loose restrictions on staying in the building ran away. The psychiatrist I was following was frustrated, bordering on irate throughout the whole ordeal. At first, I was a little put off by the doctor's emotional response and shortness with the police officers that showed up to get information on the missing person. Then I recognised this reaction. It's the reaction of a family member when someone close to them does something stupid and dangerous. It's the "if he survives. I'm gonna kill him" sort of mentality. Everyone at this campus cares about the patients as if they were family. Sometimes family disappoints you or makes you angry, but that doesn't mean you don't care. And when your patient is like family, you can't help but care about them as you care for them.
TIL: A general rule for psychoactive medications is that you have to wait ~5 days for the blood levels to level out before doing a blood test to see how the patient metabolizes the medication. And when you do draw the blood level, it should be as close as possible to halfway between doses (so for a once a day drug, wait 12 hours after the last dose).
If you're ever a psych patient and you have a sarcastic sense of humor, you may want to lay off the jokes during your interactions with the staff. The whole way that sarcasm works is by saying something that is out of character or opposite of the obvious reaction. A sane person might say the same thing sarcastically that a psychotic person might say seriously. You do not want a doctor/nurse to rely on tone of voice to understand which you mean.
The treatment for lithium overdose is emergency dialysis.
*Jenni would like me to point out that this is a bit hyperbolic as our neighborhood is not that bad.
Wednesday, April 22, 2015
WILTIMS #291-2: ♪♫ mOlé! mOlé, mOlé, mOlé... ♫♪
MondayIL: A whole new kind of mole. No, not this one or this one or this one or even this one. Complete or partial moles are types of abnormal pregnancy caused either by a sperm (or two) fertilizing a genetically empty egg or two sperm fertilizing the same egg. The latter can result in a 69 chromosome fetal mass. As we went over recently, humans can survive with a select few trisomies (an extra copy of a chromosome) but if every chromosome is duplicated, the embryo can't even develop. The resulting "pregnancy" consists of, essentially, a blob of undifferentiated cysts and must be aborted.
Diethylstilbestrol (DES) is an old drug that was used as a prenatal drug but was later found to caused clear cell carcinoma of the vagina, both in the pregnant women that took the drug and in the female children born of these women. DES was restricted from this use in 1971.
Placental invasion of the myometrium (the muscle layer of the uterus) is classified according to the depth of the invasion. Placenta accreta is attachment, increta is invasion and percreta is completely breaking through the myometrium.
TuesdayIL: A pessary is essentially a plug that can be used to keep the uterus from prolapsing in patients where surgical repair is contraindicated.
There's a nifty memory tool for remembering the difference between the main adrenal enzyme deficiencies (see the diagram to the right). With 11β-hydroxylase deficiency, both blood pressure and virility increase; with 17-hydroxylase deficiency, BP goes up but virility decreases; and with 21-hydroxylase deficiency, the BP goes down and virility goes up. All you have to remember is that ones point up!Thursday, March 26, 2015
WILTIMS #272-6: Music and a match day
This post is almost a week late, but it's finally here! I will hopefully have another big post for this week in the next couple days. Apologies for my tardiness and, as always, please comment if you have any questions!
Sunday: Over the weekend I went to a classical music concert at another nearby medical school with one of my professors (renowned for his beat-boxed heart sounds) conducting an entire orchestra composed of members of the medical field. Two of my classmates made up half the cello section! It was a really good concert and a nice reminder that not everyone in medicine needs to be a one-dimensional diagnostic robot. Also, we joked that this is one of the few orchestras where it is totally excusable for one of the musicians to need to answer a phone call in the middle of the concert. Several of the doctors in the string section had to answer pages during intermission.
MondayIL: The obturator and psoas signs are diagnostic movements that can be done by the patient to test for appendicitis. These tests work by manipulating muscles in the abdomen to tug on the peritoneum (the sac surrounding most abdominal organs) which is inflamed and will exhibit pain when irritated. These tests look kinda weird though because you stretch and contract these muscles by moving your legs. Yet another example of doctors looking crazy but having a reason. "Your stomach hurts? Well move your right leg for me..."
Ruptured esophageal varices is one of those conditions that is really terrible to treat. These varices (think varicose veins... 'cause that's exactly what they are) are a ballooning of the veins in the lower esophagus due to pressure build up throughout the portal blood system, usually due to liver disease such as alcoholic cirrhosis. The problem is that these veins are prone to rupturing and bleeding into the GI tract. Normally the body would work to clot the blood and stop the bleeding, but since the liver is failing it can't produce the protein clotting factors in the blood. At the same time, the patient is already anemic from blood pooling and lysing in the enlarged spleen thanks to that same portal hypertension that caused the varices to begin with. If you try to give the patient blood, it will just bleed back out again into the GI tract, but if you don't give them blood, they'll die of hypovolemic shock. And your stomach doesn't like blood, so the patient will often be vomiting blood throughout this process and care must be taken that none of it comes back down the wrong pipe or they'll drown in their own blood. Remember the underlying cause of all of this? Alcohol damaging the liver. Please drink responsibly.
TuesdayIL: "Acute abdomen" is a really dumb term that essentially means that surgery needs to be involved, right now. It's just a vague term for any of the numerous conditions that must be quickly ruled out when someone presents to the ER or doctors office with sudden, severe abdominal pain. If one of these conditions is suspected, then it is an emergency and exploratory surgery is often done to both confirm what the specific problem is and hopefully treat it. But since a specific diagnosis isn't necessarily know at that point, we just use acute abdomen as a placeholder.
WednesdayIL: Cholecystitis, an inflamed gall bladder, has a nifty if not entirely PC mnemonic for remembering who is most at risk - the Four Fs: forty fat female and fertile.
ThursdayIL: Alcoholics Anonymous is really religious, but kinda passive-aggressively inclusive at the same time. We had a presentation by a few local leaders of an AA group, where they held an open meeting and shared their stories. And boy were they compelling stories. We were also given a printout of the 12 steps, which I had not read before. I was surprised at how prominently "God" is mentioned throughout the steps, but after hearing one atheist's journey to sobriety and finding a personal definition of God, I was much less concerned about any conflict of sending a non-religious patient to their services. Though I have seen articles about the lack of any robust evidence that AA is the best treatment for alcoholics, I think I would be supportive of recommending that patients give them a try. I'll take as many tools as I can get.
FridayIL: Match Day is tense and emotional to watch in person. Friday was the day that nearly all the 4th year medical students in the country find out where our algorithmic overlords have contractually sent them for the next 3-5 years. I have in the past watched all sorts of videos of other schools' Match Day proceedings. Many do a big simultaneous opening of the envelopes to add to the drama. There's always a hushed silence as paper is shredded and the soon to be MDs speed read the letter to see if they got their first choice. Then there are screams of happiness, hugs and tears - most of joy, some of disappointment. The rest of the day is a big celebration with everyone running around to see where their friends will be going. The school posts the match list in the hallways and us lowerclassmen creep out of our study holes to ogle the achievements of our fellow students. T minus 2 years until that's me. Yikes!
Monday, March 16, 2015
WILTIMS #267-71: GI Mega-Post!
MondayIL: FODMAP is an oft-used acronym for the avoidable dietary causes of GI discomfort.
Fermentable Oligo-, Di- and Monosaccharides And Polyols (in english: carbs, sugars and a special type of alcohol)
TuesdayIL: Severe burns can cause acute gastritis. You might rightly wonder how hurting your skin affects your stomach. The main complication of severe burns is a loss of fluid leading to hypotension. This lack of blood causes hypoxia and ischemia of the mucosal layer of the stomach (among many other effects), leading to decreased mucus production and increased acid damage to the stomach lining.
Fermentable Oligo-, Di- and Monosaccharides And Polyols (in english: carbs, sugars and a special type of alcohol)
TuesdayIL: Severe burns can cause acute gastritis. You might rightly wonder how hurting your skin affects your stomach. The main complication of severe burns is a loss of fluid leading to hypotension. This lack of blood causes hypoxia and ischemia of the mucosal layer of the stomach (among many other effects), leading to decreased mucus production and increased acid damage to the stomach lining.
Phrase of the day: Catastrophic exsanguination - n. the act of bleeding out.
WednesdayIL: Ecstasy, LSD and similar drugs aren't really addictive substances because they don't mess with our reward centers or neurotransmitters that make you happy. They generally just cause hallucinations which, though interesting, just get old and/or too freaky after a while. They're still dangerous and can be abused, they just have limited addiction potential.
Alcohol increases sexual desire (by removing inhibitions) but decreases physiological response to said desires. "It can be less than, you know, a compelling experience that one would hope for, I guess you could say. [chuckles]" ~our pharmacology professor
ThursdayIL: Inflammatory pseudopolyps associated with irritable bowel disease look like the worm-creatures cursed by Ursula in The Little Mermaid. No? Just me?
FridayIL: Yerba mate is an Argentinean tea that's drunk fresh (i.e. still boiling) with a metal straw, causing thermal injury that can result in a higher risk of Barrett's esophagus. Barrett's esophagus is a fairly common condition where the bottom of the esophagus undergoes metaplasia due to chronic irritation, usually from GERD.
Quote of the day: "You can always get a new GI fellow, you can't get a new scope. Don't drop the scope." ~ Director of Liver Transplantation
The pancreas sucks. Besides having the worst cancer, pancreatic inflammation can easily kill you. The best analogy I could come up with to explain why is that the pancreas is like the gas tank in your car. A gas tank holds a relatively dangerous substance that is mixed with fire to create a controlled explosion in the engine. The pancreas holds enzymes that are activated in the gut to digest food. If those enzymes are activated early (throw a match in the gas tank) then they digest the pancreas which, just like the rest of the body, is made of the same building blocks as the food we eat. The pancreas effectively explodes. This releases these enzymes into the retroperitoneal space of the abdomen where the enzymes start digesting anything it comes in contact with: the liver, the kidneys, the intestines, etc. There is nothing we can do for this. The treatment is to give IV fluids and pain meds and hope the patient recovers.
Pancreaticojejunostomy is a crazy procedure used to treat chronic pancreatitis. In order to drain the dangerous secretions from the pancreas, the small intestine is bisected and part of it is used to create a new duct that goes straight from the pancreas to the GI tract.
WednesdayIL: Ecstasy, LSD and similar drugs aren't really addictive substances because they don't mess with our reward centers or neurotransmitters that make you happy. They generally just cause hallucinations which, though interesting, just get old and/or too freaky after a while. They're still dangerous and can be abused, they just have limited addiction potential.
Alcohol increases sexual desire (by removing inhibitions) but decreases physiological response to said desires. "It can be less than, you know, a compelling experience that one would hope for, I guess you could say. [chuckles]" ~our pharmacology professor
ThursdayIL: Inflammatory pseudopolyps associated with irritable bowel disease look like the worm-creatures cursed by Ursula in The Little Mermaid. No? Just me?
FridayIL: Yerba mate is an Argentinean tea that's drunk fresh (i.e. still boiling) with a metal straw, causing thermal injury that can result in a higher risk of Barrett's esophagus. Barrett's esophagus is a fairly common condition where the bottom of the esophagus undergoes metaplasia due to chronic irritation, usually from GERD.
Quote of the day: "You can always get a new GI fellow, you can't get a new scope. Don't drop the scope." ~ Director of Liver Transplantation
The pancreas sucks. Besides having the worst cancer, pancreatic inflammation can easily kill you. The best analogy I could come up with to explain why is that the pancreas is like the gas tank in your car. A gas tank holds a relatively dangerous substance that is mixed with fire to create a controlled explosion in the engine. The pancreas holds enzymes that are activated in the gut to digest food. If those enzymes are activated early (throw a match in the gas tank) then they digest the pancreas which, just like the rest of the body, is made of the same building blocks as the food we eat. The pancreas effectively explodes. This releases these enzymes into the retroperitoneal space of the abdomen where the enzymes start digesting anything it comes in contact with: the liver, the kidneys, the intestines, etc. There is nothing we can do for this. The treatment is to give IV fluids and pain meds and hope the patient recovers.
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| Source: http://insidesurgery.com/ |
Saturday, March 7, 2015
WILTIMS #266: Just a taste
What!? A one-off daily post?! Surely such a thing is not done anymore!
Well here it is, but just so you don't die of shock, it's still a day late. And don't call me Shirley.
This week was just the right length: half a day. Between study days, exam day, and a snow day there wasn't much time for actual class. We started gastrointestinal pathology/pharmacology on Friday which has already proved to be one of the grosser looking pathology sections. Mmm fatty, bloody ulcers! Amusing that the organ system in charge of eating is the one that makes me not want to...
YesterdayIL: Several antipsychotic drugs can be used as antiemetics (anti-nausea/vomiting medications) but you get all the nasty side effects, so they are usually not your first choice.
There is a relatively common congenital abnormality known as tracheoesophageal fistula where the esophagus doesn't form correctly and instead comes off the trachea. The vast majority of cases have a particular arrangement where the esophagus dead-ends right after splitting off from the trachea and then the lower esophagus connects to the respiratory tract near the branching of the main bronchi. Nearly every other connection combination is possible, but all are far less likely. All of these are discovered very quickly and, assuming nothing terrible happens first (like the baby aspirating food and developing pneumonia), it is easily surgically corrected.
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| Type C is the most common. source |
Schatzki's ring is a pathological finding that is seen with a chronic sliding hernia of the stomach up through the diaphragm. In case you, like me prior to med school, don't exactly know what a hernia is: a hernia is any condition where part of an organ protrudes through the cavity containing it. Some types you may have heard of are an inguinal hernia, where intestine escapes into the groin area; an umbilical hernia, where the intestine pushes through the relatively weak area around the belly-button (umbilicus); and a hiatal hernia, where the stomach slides up through the diagram... which can cause scarring and a Schatzki's ring! Woo, made it back around!
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