MS1 Day One

Medical school has begun -- my first day of true classes are tomorrow, but already I have the stack of books and notes and powerpoints and all, and I'm at my desk with my books open and my pencil at the ready.

...that said, it's about laboratory microscopes and staining, so I thought I'd take a nice departure and update this quickly.

I'm (clearly) full-time just like all my peers. My 25-credit course load this semester is:

• IDC 101 -- Molecular and Cell Biology with lab and small group (a multidisciplinary class that covers topics including embryology, immunology, the cell cycle, metabolism, inflammation)


• IDC 103 -- Anatomy with lab (exactly what it sounds, complete with cadaver; our school isn't one that "converted" to virtual human models)


• IDC 135 -- Ethics and Legal Topics in Clinical Medicine with small group (case studies to develop compassion, I hope)


• IDC 136 -- Interviewing and Physical Exam with small group (an attempt to teach us how to do a physical exam on standardized patients, and develop effective communication)

I have, on average, 35-40 hours of lecture/lab a week, so don't ask me how I'm supposed to fit in studying too! They also keep preaching this concept called balance. Hmmm... I wonder what that is.

I also received the short white coat at Friday's ceremony, marking the official initiation of my class as medical students. We recited this Student Physician's Oath, which while meaningful, felt a little ridiculous and unrehearsed as it took us by surprise as we walked in and took our seats to find a paper with the oath on our chairs.

Prednisone and Clindamycin

Yesterday I noticed that I was dribbling water when I tried to rinse out toothpaste, so I stood up and tried some facial expressions, with the result that my smile was only to the right side and I couldn't "sniff" up one side of my nose. I ended up going to the ER.

Fortunately, no, it is the farthest thing from a stroke. It wasn't truly a medical emergency, but given that it was Saturday midday, there wasn't much better I could've done. Ideally I would've gone directly to see my otolaryngologist (ENT specialist). Evidently I have a middle ear infection with neuritis (inflammation of my facial nerve), causing weakness in the left side of my face. My blinking doesn't match up -- the left side is delayed and doesn't close completely, my eyebrows don't raise evenly, and I can't quite scrunch my left eye closed.

So I'm back on more antibiotics and now prednisone. When I heard I was going to be placed on prednisone my words were, "Oh great! Fabulous!" Sarcasm fully intended. I know well enough from the hospital that it's a very strong anti-inflammatory steroid, and once someone is placed on it, they actually have to go on a tapering schedule to prevent withdrawal and disruption of normal hormone production.

Prednisone is a prodrug that causes increased corticosteroid levels, which means it messes with the feedback loop between ACTH and the gluco/minerocorticoids in the body. Furthermore, this drug has some pretty nasty side effects. It's used sometimes in treating asthma, so I had it before as a child. Apparently I became withdrawn. My father warned me to recognize if I became too hyper, careless, or aggressive.

Clindamycin, on the other hand, is the antibiotic. This is the third time that the same facility has tried to prescribe me cephalosporin, to which I'm allergic. So know your medication names -- I now know that Keflex is another name for cephalosporin. Cephalosporin interferes with the bacterial cell wall, much like penicillin. Instead, clindamycin interferes with protein synthesis in bacteria. It binds to the larger ribosomal unit (50S) inhibiting formation of the full ribosome complex, preventing translation from the mRNA into a protein. It does this by inhibiting the enzyme transpeptidase.

Hopefully this resolves quickly.

The Patient Came in for Tachypnea

We got a patient yesterday, status post cardiac arrest, successfully converted by EMS. Everyone became excited as we set up the room in anticipation of that cardiac arrest, only to have the patient come in stable and go directly to PICU since the bed was ready.

At least in the back there was a bit more excitement -- we had a little baby recommended to see a pediatrician for breathing too fast and low oxygen saturations, hovering around 93%, which should've been 98-100% normally, but under 90% is when we're worried. The ARNP and physician at first thought this was all psychological, then they saw the face become dusky when crying, and began thinking perhaps she had a CHD -- congenital heart defect.

A chest x-ray was obtained:



One can see the heart displaced to the right, as well as bowel literally up in the thoracic cavity (the soft tissue mass on the left), leaving not very much "clear black" where lungs should be. The fact that the patient was a few weeks old and still maintaining saturations is incredible. This condition, a birth defect called diaphragmatic hernia, is generally life-threatening and requiring neonatal resuscitation and intensive care. It is also quite rare, occurring in about 1/5000 births.

The patient did end up needing to go to PICU mainly for surgical preparation and stabilization.

Swine Flu

Swine flu continues to affect my hospital -- I had an exposure at work through a resident who came to work just before onset of symptoms. Staff exposures led to over 150 patients and other staff members being potentially exposed, and then screened for symptoms. These exposures are ongoing, as we continue to have staff members screened and staying home for several days if they develop swine flu.

Since I had no symptoms, I was put on prophylaxis, and had to take Tamiflu (oseltamivir) for ten days. Fortunately I didn't notice any side effects, but some of my coworkers were pretty unhappy with having to take any medications at all. Personally the cost of having come down with it would have been prohibitive, as they were mandating at minimum 7 days without work, which is half a paycheck for me, plus a loss in benefit accrual for that week.

It's an interesting and essential debate -- there's much made of naturopathic physicians and midwifery that advocates natural healing, herbal/vitamin supplementation, and caution before using Western medicine, but most of these people work within those scopes. However, there's a growing subset of people who work within Western medicine (in nursing or medicine, primarily) who also are cautious about using any sort of medications, who pride themselves on avoiding Western medicine as long as possible.

Where's the balance? There is certainly justification to the idea of not using antibiotics so readily, as we've seen the rapid development of several drug-resistant microbes but far is it until we undermine the principles on which Western medicine is based?

Prevention should be one, which is often neglected. But we were using Tamiflu for secondary prevention through the act of prophylaxis, which is based on the Western medicine theory of immune response and drug-antigen interactions, not solely the body's capacity to withstand an exposure. If we forgo aggressive containment of an ongoing epidemic (H1N1/Swine flu) because so many people refuse to take prophylactic treatment, therefore potentially thwarting attempts to stave the epidemic, then are we undermining Western medicine?

This is similar to the argument about annual influenza vaccinations. I am all for them, because since I started receiving the flu vaccine several years ago, I have not been personally ill with the flu, and I know I am likely not responsible for transmitting flu personally to any of my patients at work, some of whom could be seriously ill compared to the general population. Some Children's hospitals mandate the employees get one with 100% compliance, but most hospitals just "recommend" that employees receive one. There is a statistical difference for workplaces that have higher influenza vaccine rates and the rate of nosocomial (hospital-acquired) influenza. Which leads to better outcomes for the patients as a group. Which leads to less cost since anything hospital-acquired has to be paid by that hospital.

But there's of course the flip side with the fear that they do nothing, or that they even cause allergic reactions and autism and so on (most of which are unsubstantiated). Some of these people work at the hospitals. Are they then viewable as threats to maintaining hospital culture?

It's a thought.

H1N1 Flu Update

So I mentioned in the last post the impact of our first suspected H1N1 flu case in the state (the proper term is no longer "swine flu" in honor of people who do actually eat pork and those who sell it -- go Iowan farmers!).

Thursday morning, we received the breaking news of 3 suspected cases of H1N1 flu, including one in a child and one in a pediatrician.

That day, the Emergency Department saw 184 patients. For comparison, our average caseload a day is in the 80s or 90s, and last year, on the same day/time of the month, we saw 88. It has been dramatic. Our infection control adherence has stepped up enormously.

On Monday, any fever/cough patients had to have traveled to Mexico or San Diego to be considered H1N1 flu-material. By Thursday, anybody with fever/cough was automatically put in our "strict isolation." Strict isolation means that we had to wear gowns, gloves, and special filtering masks (like the PAPR masks I've described before, for tuberculosis).

We've also now shut down some of our operations -- some entrances are closed, staff cannot work for seven days if they have any indication of a cough/cold (I saw a poor coworker sent home after an entrance screening for just sniffling, despite her protestation that she had no fevers whatsoever). Our snack cart in the Emergency Department was removed, and our families are not allowed out of the rooms, H1N1-suspect or not.

This is insane! And exciting!