WILTIMS #213: Unfair advantage with unfair news

Sorry, I don't have a TIL for this post. Instead I want to write about a topic that I know a little too much about.

Today we talked about how to break bad news to patients. After a short lecture, we broke up into small groups with real patients, in my room's case a breast cancer survivor, who had been given difficult news in the past. It was weird having someone come in and speak whom I could very much have replaced, had there been a need. I also felt like I was cheating when it was our turn to ask questions.

"I feel like that period between your initial irregular test result and your actual diagnosis must have been scary and confusing..." I say like a lawyer leading my witness. "Could you describe to us how you felt?"

The afternoon after my biopsy (a "fine"-needle aspirate of my mediastinal mass) was the most pain I've ever been in. I hurt in every way. My chest hurt where they stabbed me, my swollen sentinel lymph node still radiated pain down my arm, I was terrified that it was something even worse than it turned out to be, and I was surrounded by loving, equally-scared family who wanted nothing more than to help me, but who sat watching helplessly as I sobbed in the fetal position on my grandparents' couch. I just wanted to go home after winter break like I was supposed to, but my life had changed on that fateful Friday, three days prior.

And that was one of the big takeaways today. It doesn't take a metastatic cancer diagnosis to make for a difficult diagnosis discussion. Anything that will change someone's lifestyle or plan can be hard to handle. We need to amputate. You will need to take this medication for the rest of your life. You won't be able to play that sport/ do your job/ get around unassisted anymore.

I got my final diagnosis by phone, because the doctor wanted, as soon as possible, to reassure me that it wasn't something worse. So, I never really experienced that "bad news" talk from the patient perspective; my cancer diagnosis was relatively good news! I have, however been closer than most to the other side of the conversation.

After I recovered from my treatment, I volunteered with the Cancer Resource Center in the Ithaca. Among other things, I volunteered on thyroid clinic days, where 5-10 people would come in for a biopsy on potentially cancerous nodules on their thyroid. About five of every six patients would come in, be nervous for an hour or so, and leave relieved. But nearly once per clinic, someone would test positive. They were diagnosed with cancer, right there.

The doctors at this center were great; they would deliver the news and take as much time as was needed for the patient. But when they reached a comfortable stopping point, they would offer the assistance of volunteers like myself to talk with the newly diagnosed patient in a private room about the steps ahead and the resources available to them as they started this struggle.

We really never expected people to understand anything we said. Once someone says the C-word, everything else is white noise. We really were there for three reasons: to just be present for the patient as they start to digest the news (i.e. hold the Kleenex), to offer up support as someone who has been in there shoes and had come out alright, and to make sure they left with a big packet of materials that they could open up once the shock had abated.

That was another takeaway from today's discussion that I hope my classmates remember: The moment of diagnosis is so overwhelming that you need to assume the patient understands nothing, but will probably want to know everything once they have gone home, grieved, and begun to process the change that is about to happen in their life. Some people weep, others are stoic, none are grasping the details right then. So make sure they know, at bare minimum, when and where their next appointment is and that they have access to all the information you are telling them once they get home.

Lastly, and a point that I feel wasn't greatly stressed in our lecture today, when it's appropriate in the conversation, bring up family and friends. Some people are far less concerned about themselves than how their spouse, their children, their parents will handle the news. The patient's care should be topic #1, but a diagnosis like this is usually devastating to more than just the person in the room.

These conversations are very difficult and emotionally draining, but I've never felt more useful to a person than when I could help someone take the very first steps on the road back to normal, in the moments after they've never felt more lost. If you do it well, nothing is more rewarding.

WILTYIMS #212: Static

Apologies for the repeat tardiness; headaches don't make for productive bloggers. I actually got some sleep last night [gasp!] and am feeling much better.

Yesterday I learned: antibiotics are complicated:

Click to see the full-resolution original

I made another thing, but this one is just for me (and classmates who read my blog, I guess). It's nowhere near complete yet, but gives you an idea of some of the common drugs used to treat microbiotic infection and their mechanisms of action.

Tetracyclines (including the eponymous tetracycline and also the popular doxycycline), macrolides (including erythromycin and azithromycin), and clindamycin all target bacterial ribosomes. But whereas clindamycin and the macrolides disable the 50S subunit, tetracyclines go after the 30S subunit. None of these drugs are actually bactericidal - they don't kill bacteria.

What use are they if they don't kill bacteria? you might ask. By targeting the ribosome, these drugs stop the bacteria from effectively making proteins, thus stopping most cellular function and division. this can give your body enough time to take out the infection on its own. That can be for the best if you are trying to build up a robust immune response and create immunity through antibodies.

WILTDBLIMS #211: Hepatitis and productive procrastination

This is the tardiest I've even been for this blog, but I was working on something else that I'm quite proud of:

Click to go to the full resolution Google Drawing

That diagram is just the classification information on most of the viruses we need to know for our microbiology final next week. Of course, we also need to know the pathology and treatment for each of the diseases these viruses cause - not to mention all the bacteria and parasites we need to review in the meantime... Gonna be a "fun" week!

What I learned the day before last: Hepatitis! Everyone has heard of hepatitis and probably even knows that there are three common types: A, B and C. But do you know what hepatitis actually is? Hepat- means liver and -itis means inflammation, so any hepatitis is an inflammatory process of the liver. The lettered bits refer to specific viruses that affect the liver, causing a form hepatitis.

{brace yourself for all the TLAs^*}

Something that I didn't know until Friday was that the viruses that cause hep A, B and C are totally unrelated. Hepatitis A virus (HAV) is a tiny picornavirus, HBV is an hepadnavirus, and HCV is a flavivirus. HAV and HCV use RNA for their genetic material, meanwhile HBV uses DNA. HAV is transmitted from feces; HBV and HCV are passed on through blood and bodily fluids. Most importantly, HAV is quickly recovered from while HBV and HCV often lead to chronic, lifelong infections and severe liver damage.

There are also viral hepatitises D and E, as well as a few other viruses that are suspected of being associated with hepatitis but have not earned a letter yet. And all of these are very different as well. Isn't virology simple? (in case the sarcasm didn't just drip from that last sentence, take another glance at that chart above)

*three-letter acronyms

WILTIMS #210: ♪♫ Stool-day, bloody stool-day ♪♫♪

TIL: Blood in stool is more complicated than one might think. When my pathology small group leader asked us whether the bloody stool described in a case study was left-sided of right-sided, one of my brighter classmates turned to me and mouthed, "What the f*%#?" I nodded in confusion. How can you tell which side of the colon is bleeding from a description of the bloody stool?

With a little bit of more explanation we both got it. You can tell where in the GI tract the patient is bleeding by how digested, and thus black, the blood is. If it's still red, then it's relatively fresh and likely to be located near the end of the colon or around the anal opening (generally toward the lower left side of the body). If it's black, then it has been digested by its passage through the GI tract. Black blood can originate anywhere upstream, like the stomach or small intestine, but if it is in the colon, then it's on the right side of the body.

WILTIMS #209: Violet! You're turning violet, Violet!

TIL: If you see an ear defect at birth, look at the kidneys. These two structures develop at the same time, so if something non-congenital like an infection or teratogenic substance (alcohol, drugs, tobacco) caused a malformation of the ears, it is likely to have altered the development of the kidneys as well.

Rubella causes blueberry muffin babies. They are not tasty or part of some twisted fairytale, but bleeding from small blood vessels under the skin, giving them bruise-like marks reminiscent of a buried blueberry in a muffin.

Stridor is a high pitched squeak typically heard upon inspiration and caused by an upper airway obstruction. This is in comparison to a wheeze which is usually heard on expiration and caused by a lower airway obstruction, as with asthma. The prototypical cause of stridor in young children is croup (aka laryngotracheobronchitis), a viral respiratory infection of the vocal cords and windpipe.

There was a moment today, which happens periodically, when a professor assumes we know some basic term that, due to our complete lack of experience, we don't. Today's was "coryza," which is the fancy medical term for having a runny nose and watery eyes.

And lastly:

TORCH is yet another really dumb mnemonic. This one is for the types of infections that can be transferred from mother to child during pregnancy or birth.
    Toxoplasma
    Other (parvovirus B19, varicella, clamydia, ghonorea, etc)
    Rubella
    CMV
    Herpes, HIV, Hepatitis

WILTIMS #208: Stupid, fat hobbit. You ruins it!

Quote of the day: "Death is not good." ~Pathology course director

TIL: Coney island is named for rabbits (the old dutch name was Conyne Eylandt and the english one was Conney Isle; both versions of Coney mean rabbit). The rabbits used to cause a significant number of cases of tularemia, a bacterial infection that's carried by rabbits, in the Brooklyn/NYC area.

Recurrent and recrudescent are very similar words used to describe infections. The former means an infection that has returned due to repeated exposure to the infectious agent; the latter is a breakout that originates from within the person due to the original infectious exposure. 

WILTIMS #207: A pox upon you!

Herpes is a word that has morphed many times in my mind. In early sex-ed classes, I associated it with the barrage of sexually transmitted infections that the teachers accost your senses with (hopefully just sight), like gonorrhea, chlamydia, and syphilis. Then in high school, as with so many "facts," I learned that it wasn't quite so simple: herpes is also the cause for cold sores. It was a great conversation piece for all those herpes conversations that came up...

But as I experienced more and more of biology and medicine, both in high school and undergrad, I heard the word herpes come up over and over with all manner of seemingly unrelated illnesses. I had kind of accepted that it must be some broad term that isn't used by the general public. Turns out, I wasn't far off!

TIL: Herpesviruses are a broad family of viruses that include many disease-causing bugs of which you may have heard. There are eight types of human herpesvirus (HHV):

1. cold sores
2. genital sores
3. chicken pox/shingles
4. Epstein Barr (causes mono and several lymphomas)
5. cytomegalovirus (usually asymptomatic in the immunocompetent)
6. roseola (aka "sixth disease," one of the principle rash-causing diseases in infants)
7. also causes roseola
8. Kaposi sarcoma (used to be super rare, until the rise of AIDS)

And don't think that it's that simple, either. Type 1 (cold sores) can be found on the genitals and type 2 (STD) can cause cold sores (this cross-contamination shouldn't be too surprising given some common sexual practices). Furthermore, given the opportunity, either of the above can cause systemic infections including viral meningitis.

A one-dermatome rash caused by shingles (HHV-3)

Zoster, as in the varicella-zoster virus that causes chickenpox and shingles, means belt. It is used to describe the shingles form of the infection because of the telltale belt-like rash often seen in symptomatic patients. Herpes often sits latently in nerves throughout the body. When the HHV-3 becomes reactivated it will cause a rash throughout the area innervated by that one nerve. This leads to some anatomically interesting rashes that only affect one dermatome (the area serviced by one spinal nerve segment).

Poxviruses are a broad classification of viruses that include smallpox (as well as cowpox, monkeypox, etc) and moluscum contagiosum. By the way, unlike cowpox and monkeypox which are carried by and contracted from those respective animals, chicken pox has no connection with chickens. In fact chickens are immune to chickenpox. It is thought that the name cropped up as a way of indicating how mild the disease is compared to the better known pox, smallpox.

It was weird talking about smallpox today, because the last known diagnosis of the disease was in 1977. And it's kinda sad that the only reason we learn about it is for in the event of a bioterrorist attack.