WILTIMS #474-8: Pulm Week 2

After finishing my first elective in a medicine subspecialty, I'm pretty sure I never want to specialize in any one organ. Doing just lungs or just anything everyday seems really monotonous to me.

My other takeaway is that, while surgeons often ignore patients on purpose, medical doctors can still ignore patients accidentally. One of my attendings this week had a habit of thinking out loud to the rest of the team while standing over the patient - not a bad thing necessarily. But then he would occasionally keep thinking out loud and just wander out of the room without ever summarizing or saying goodbye to the patient. I started to lag behind to quickly translate to the patient what I thought was going on. To my classmates: please don't pick up this habit. It makes otherwise kind and considerate doctors seem like assholes.

MIL: Sickle cell disease can increase reticulocyte (immature red blood cell) levels which can be mistaken for white blood cells (WBCs). Leukocytosis (high levels of WBCs) indicates inflammation, usually caused by infection, so these patients can be needlessly worked-up or treated for an infection they don't have, if you don't think about this common lab test error.

TuIL: A cheap treatment for sleep apnea is having the patient wear a shirt with a breast pocket backwards and put a tennis ball in the pocket. This way, the patient can't lie flat on their back, which is one of the ways to stop the airway from collapsing in sleep apnea.

WIL: The PaO₂/FiO₂ ratio is the ratio of the pressure pf oxygen in the arteries to the oxygen content of the inspired air. It is a simple way to estimate lung function and used to categorize the level of adult respiratory distress syndrome (ARDS).

ThIL: Telephone standardized patient encounters are weird but not as scary as people tend to think. Most of our practice patient encounters are in person, talking to and examining an actor. But part of our board exam that I take this summer includes telephone interactions, where you enter an examination room and call an actor in another room. Usually this is one of the ways that they test students' proficiency in patient care related to pediatrics, as having child actors would be problematic.

FIL: Extracorporeal membrane oxygenation (ECMO) is an attempt to make for the lungs what dialysis is for the kidneys. It is essentially a less-than-fantastic artificial lung that is sometimes used in ICUs when a patient's heart and lungs aren't doing a good enough job at oxygenating blood.

WILTIMS #253-6: I kidney you not

Heart -check, lungs -check, brain -check! On to the next organ: kidneys! Compared with the previous three, the poor kidneys get no respect. But when things go wrong for your determined little blood filterers, you'll notice ...and/or die. 

Tuesday: I had a preceptor visit today where I had my first experience with an interpreter. I'm actually amazed that it took this long! Last year, the doctors I worked with were both fluent in a several languages and mostly cherry-picked the english-speaking patients for me, so they wouldn't have to play both doctor and interpreter.

Today's patient was a ~80 year old woman who came in with her grandson. The patient spoke no english at all but her grandson was extremely well spoken. I quickly saw, as we were warned in our FCM class, that a using a family member as an interpreter could be dangerous if you don't trust the interpretation or motives. Even something as innocuous as "I'm sure what she means is..." can dramatically change the narrative you're hearing from a patient and the clinical picture you base medical decisions on.

This particular interview went surprisingly well and I think I was able to get nearly all the information I wanted. Figuring out the type of pain being felt was particularly difficult. It wasn't sharp, dull, stabbing... and whatever the word was she saying didn't quite translate. We eventually settled on "tingling," which matched the our physical exam findings of nerve-associated dysfunction.

TuesdayIL: There are two broad syndromes of renal dysfunction and they are super-helpfully named: nephritic and nephrotic syndromes. Nephritic patients will have blood in the urine (hematuria), protein in the urine (proteinuria), high blood pressure, and a low urine volume. Nephrotic syndrome, by comparison, is markedly more severe proteinuria, low blood albumin levels (hypoalbuminemia), generalized swelling (edema), and high blood lipid levels (hyperlipidemia). Simple, right? And these are just broad categories that each specific renal disease shares some combination of features with.

WednesdayIL: Red blood cells should never be in the urine, but their morphology, when present, can hint at where the bleeding is happening. Crinkly red blood cells in the urine typically come from the upper urinary tract or kidney. This is might relate to the multiple changes in concentration and/or just being in the urine for a longer time. Normal looking red blood cells generally come from lower, in the ureters, bladder or urethra.

ThursdayIL: Foamy urine is indicative of severe proteinuria.

FridayIL: The indications for dialysis can be remembered by the mnemonic AEIOU:

Acidosis (low blood pH)
Electrolytes (ion imbalances)
Intoxication/Ingestion (toxic substances)
Overload of fluid
Uremia (severe blood loss through the urine)

WILTIMS #194: Target aquired

TIL: Anisocytosis is the variation in size of red blood cells (RBCs). RBCs normally have a very consistent morphology, so when they look different it is an easy indicator of pathology. RBCs are recycled about every 4 months, meaning that about 1% of the circulating RBCs should be brand new immature cells. Too many young RBCs (which look bigger and greyer) mean that the body is producing more red blood cells (likely in response to their destruction in forms of anemia). To Too few immature RBCs can indicate other underproduction anemias.

Some of the morphological changes that can occur include the formation of very faint RBCs, due to disorders of hemoglobin synthesis or iron deficiency; sickle cells, which are formed due to aberrant hemoglobin polymerisation; and target cells, which produce an extra large cell membrane resulting in a extra fold that makes them look like targets.

The pictures to the right show all of the variations I described above. In order: an immature RBC (polychromatophilic macrocyte), faint RBCs from severe iron deficiency (hypochromic microcytes), sickle cells, and target cells.

WILTIMS #177: Bones, ebola, blood, and a bunch of boys

Today was surprisingly fun. We started off with some great lectures by two medical examiners for our county. The first was so deadpan it reminded me of Bones. "Our hospital is a regional trauma center, so people come from other counties to die here," she said, completely deadpan.

For lunch we had a (catered) lunch panel put on by the infectious disease interest group about the ebola outbreak in western Africa. The moral of the story from the dean of the school of public health was that, while ebola is nasty and we should stay informed so that we can calm the public, the flu will kill tens of thousands of americans this year (like every year) and we'd save more lives urging people to get their flu shot than anything we can individually do about the hemorrhagic fever that's making headlines.

In the afternoon we had a microbiology lab, where we got to perform several laboratory tests, including confirming our own blood types (A+ confirmed!). This was the first time we've gotten to stab each other so far in our training. The blood typing was surprisingly easy (if you have serum antibodies for A, B and Rh factor lying around). Just mix a drop of blood with each of the antibody solutions and see if the RBCs clump. Only one person we tested found a different result from what they thought their blood type was. Still not sure how that happens...

Finally, this evening I went to my first volunteering event of the year at the nearby juvenile detention facility. This year, I'm co-president of the club that organizes this and it was fun leading the activity we did today. It's one more thing on my already over-full plate, but well worth the effort to bring a little fun to some really nice if troubled kids.

TIL: Cranial gun shot wounds (GSWs) can appear stellate (star-like) because the tiny distance between the skin and attached bone of the skull can't diffusely distribute the force of the impact resulting in blunt force tearing. Also, entrance wounds are usually rough around the edges because the spinning bullet tears at the tissue as it twists through the skin. This is usually not the case by the time the bullet exits the body (if it does so).

In front-impact car accidents the driver often dies from internal bleeding due to a transected aorta. The location of the tear is often very specific to the site of the insertion of the ligamentum arteriosum. As a random aside, I haven't mentioned that vestigial shunt since over a year ago! Time flies when you're having... let's call it fun.

WILTIMS #164: My thumb hurts

The ever exciting med school flag football season has started up at my school, and after some crazy team-trading drama, we had our first game today. Predictably, I quickly hurt myself by jamming my thumb into someone's hip while reaching for a flag. Jamming is a technical term...

Later in the game as our artificially high score passed 100, I turned to a teammate and, while still rubbing my sore thumb, exclaimed, "Wow, I think we just broke three digits!"

I immediately knew I should have phrased that differently when he looked with a shocked expression down at my hand. Only at a med school flag football game, would he think I was casually commenting on breaking three fingers.

TIL: Red blood cells actually participate in the body's immune response via the complement system. Though they have no nucleus and are generally pretty useless, red blood cells express complement receptors which can bind to antigen fragments and bring them to the liver or spleen, where they are taken up by macrophages for incorporation into the adaptive immune response.

Of course, red blood cells also cause the immune system some problems too; they do not have the ability that most other cells do that tells the immune system they are infected. It's like a bank without a silent alarm and malaria is the crook that has cased the joint. Once inside, malaria is invisible to the immune police. The silent alarm in this case is major histocompatibility complex (MHC) class II, which displays pieces of an infectious agent, alerting the immune system to the infection (and begging for a mercy killing).

Also, it is loosely estimated that there is a 1% decrease in renal function per year after the age of 25. Woohoo, still 98% functioning!