Saturday, January 30, 2010

The Shadow in White

These past few days I've been doing some doctor shadowing - an infectious disease (ID) specialist on Wednesday and Thursday, and my mentor (a pediatrician) on Friday. It might not have been the wisest timing to do my shadowing, what with my first block of exams this coming week (then again, I shouldn't be blogging right now for that same reason . . . oh well).

Anyway, I was a bit hesitant to blog about this in some detail, as I had to look up the HIPAA (Health Insurance Portability and Accountability Act) that would put me in deep trouble if I disclosed certain info. So I looked up the 18 personal identifiers that I'm supposed to avoid. Ironically, we as M1's haven't had HIPAA training yet. Fortuitously, I don't know any of the 18 personal identifiers for any of the patients that I saw, so there's nothing I could really disclose anyway. So without further ado . . . (this post is long).
Wednesday - ID Inpatient

I spent almost 4 hours of my afternoon shadowing an ID attending, I'll call him Dr. P. I met Dr. P at the LGBT meetings, as he's the faculty adviser for the group. I'm pretty sure he's gay and super nice and kind of funny (I guess I may have a tiny crush on him) . . . beside the point! Once I discovered he was ID, I kind of stalked him at these meetings so I could get his contact info to shadow him. Don't look at me weird, a lot of med students do this.

After wandering around the hospital for a while looking for his office/clinic area, I finally found it and waited several minutes for him to arrive from . . . probably seeing a patient. He came in with another doctor, a nephrologist (who I guess was doing a rotation through the department or something, idk). Anyway, the nephrologist has pretty long hair and amusingly, some of the patients we saw that day referred to him as "Dr. Long-haired." I sat and listened to the nephrologist present a case to Dr. P.

After the nephrologist finished presenting the case, Dr. P turns to me and asks, "So, did that all make sense? Do you have any questions?" After saying no, he quickly responded with "Psh, come on, of course you do. Don't be shy." At this point, my mind was racing to come up with some question to ask. So I asked, "Well, this patient is anemic. Is there a family history of anemia?" Apparently, that wasn't something either of them had thought to ask the patient. WIN. (Ron, if you read this, for the love of God come up with questions to ask - they're hard to think up on the fly.)

The nephrologist leaves and Dr. P and I go to see a patient. I had never been in the areas of the hospital where patients were, so I was instantly lost. The first patient we saw was a middle-aged guy who got an infection in his leg, and they had no idea where it came from or how it got under his skin. So they wanted to take some of his white blood cells, tag them with some kind of radioactive tag, inject his white blood cells back into his body, and see where they go (and hopefully they'll go to where the entry of the infection is).

After that we went to one of the doctor's stations where he typed up a note on the EMR (electronic medical record). He kept all these sheets of papers on his patients folded lengthwise in one of his pockets, which I found amusing. He showed me this one patient of his, who they called "The Train Wreck" because he had been in the hospital for months and kept getting different infections (somehow). They don't know what to do with him. He showed me this guy's labs and he had 3-4 simultaneous bacterial infections. I didn't know a person could be infected with so many bacteria at once, and all resistant to most of the meds they had!

He finished the note and declared that he was hungry, so we were off to have lunch. I just got a sandwich, which he paid for, and we sat and ate together. Being this close, I saw that his left ear was pierced (no idea why I noticed that). We chatted for a bit before heading up to meet with his fellow and M4 for afternoon rounds. On the way he asked me why I joined the LGBT group. I was caught off-guard and gave some lame (but true) answer about how I was interested in LGBT health issues and thought the group would be helpful. Alas, the group isn't (helpful, that is). Dr. P was really concerned about the future of the group because so few students in my class show up to the meetings.

We went up and met with the rest of his team. The fellow presented a case of this elderly woman with an echinococcus infection that they don't know what to do with (echinococcus, a kind of tapeworm parasite, is rarely seen in the US and is considered a "3rd world disease"). The case was frustratingly complicated though I'm not sure I can say more on it. We finally went down to see her in the SICU (surgical ICU). It was so sad looking at this patient and being unable to really do much for her, due to the complicated nature of her illness. You could see the doctors' frustration.

Then we went to the MICU (medicine ICU) to check in on another patient, who was comatose and undergoing a lumbar puncture when we arrived. We didn't even enter the room and I forgot what kind of complicated infection she had; all I remember was that she has liver cirrhosis. After a few minutes of just standing in the hallway, with the fellow explaining her case to me (which, again, I sadly forgot), we went to see the woman whom the nephrologist had presented on earlier.

She was in her 20s, was admitted with pretty serious anemia, and had an ELISA test indicating she was HIV+. When the 4 of us entered her room and closed the door, the tension became palpable - you could almost cut it with a knife (I was never really in a situation where that applied, until now). Dr. P asked about family history of anemia and then began the quiet conversation with her that she might be HIV+. The ELISA test is great for telling someone they're HIV-, but if a person tests HIV+ it may be a false positive. So a Western blot is done to confirm the diagnosis. Dr. P ordered a viral load instead as the Western blot is done elsewhere outside the hospital and takes 3 days to get the results, whereas the viral load test is done in-house and takes a day (but is more expensive).

When we were done talking with her, we stood in the hallway for a few minutes. Dr. P was complaining about how one of the other departments (I think it was pathology) blamed her anemia on the HIV even though it hadn't been confirmed yet. We all agreed it was lame, as HIV can't cause anemia. Dr. P kind of mocked pathology sarcastically, like "Oh look at that anemia, it's HIV's fault. No it's not, that's just lame."

With that, it pretty much concluded my time on rounds with them. They were surprised to get done at around 4pm, as it usually goes for much longer. On the other hand, I couldn't believe how long rounding took on so few patients! Dr. P apologized that I happened to shadow on a day with very complex cases, and kept reassuring me that there are days where the cases are straightforward and you can go home knowing you've solved a case and have definitively helped someone. Not so today, and it was rather House-like.
Thursday - ID Outpatient

The following morning, I returned to the Dr.P's office/clinic area. On Thursday mornings he does outpatient HIV clinic in the hospital. So we saw several HIV patients. It was much more chill than ID inpatient.

For some of them, he was basically managing their care and serving as their primary care doctor. The patients I saw were really nice and overall pretty upbeat. Several of them were teasing and harassing Dr. P playfully, probably because I happened to be there. More than one was like, "I take my meds because if I don't, this guy here [points to Dr. P] gives me a look that slits my throat with his eyes." At which point, he does. It's pretty funny actually.

One patient was like, "I was in the hospital a few weeks ago and you didn't come to see me! I kept looking and looking for you." Dr. P was like, "Well I didn't know! Do you know how many doctors there are in this hospital? Over 800, and I don't know them all. You should've called me." Dr. P then asked if he had made an appointment with his nephrologist. The patient says, "No, because he's not you." At this, Dr. P wonders if there's something about the nephrologist he doesn't like so he could refer him to another one. The patient reassures him that the nephrologist was a fine doctor, he just wasn't Dr. P. I thought that was rather touching. :-)

According to Dr. P, these patients were the super compliant ones. They keep their appointments, the maintain their drug regimen more or less on schedule, they have a social support to help them, and they're not confrontational. All of them were on a cocktail of antiretroviral drugs. But man, are those drugs expensive! A supply of 3 pills costs about $2000 (I don't know if that's per month or per year) and this one patient was waiting for his tax return or something until he was able to pay for the next prescription refill.

It just makes me wonder how horrible it would be if these patients didn't have at least one other person - like a family member - to help take care of them, or if they weren't able to pay for their meds, or if they're unable to take their meds regularly at the specific times. That must be a nightmare. These are life-sustaining pills and if you forget to take them precisely, it could make things messy as HIV quickly develops resistance - leading to more complicated drug regimens.

Also surprising was what Dr. P told me the ages with the fastest growing incidence of HIV cases were: between 15 and 25, and older than 50. Dr. P had one 19-year-old patient who missed his appointment. That's some scary stuff, so people remember to use condoms every time!!

Oh, and the woman's test came back confirming HIV+ status. Dr. P paged every person on his team, as well as the nephrologist and a social worker. I didn't stick around to see what was going to happen, but as it is, there would be 5 people entering her room at the same time to talk with her. I hope everything went okay.
Friday - Peds Outpatient

Okay, by now this post is long enough. This visit wasn't dramatically different than the last 2 times I shadowed my mentor so I'll keep this short.

Notably, I heard rales (crackling sound in the lungs) in one kid, and my mentor ordered a chest x-ray on her to rule out pneumonia. I was so proud of myself for actually hearing it. And I saw scarlet fever on another girl. It was pretty classic textbook scarlet fever.

There were many kids with strep infections, and I kept hoping that I don't catch it as it'd be really bad for me to get sick during exam week. Though . . . if I end up getting strep, everyone in the room with me would get infected by the end of the first exam . . . Anyway, thank God for hand sanitizers in every room.
So that's it. I had to read through this a couple times and edit out details (so just know that it was longer still, lol). I actually really enjoyed ID, I thought it was fascinating. I still like peds though, so we'll see what happens from here.

Now to study more for my neuroscience exam on Monday . . . *Sighs*


Ron said...

well i sorta told u all the comments i had to you on msn lol... but yea good luck on your neurosci exam!! i have neurosci coming up this semester -- oh noez :C

and haha, thanks for the tip. i hate thinking up of questions on the spot. its annoying. I love med but i'm not the genius (or suck-up) type that pretends to be intensely curious about everything

take care


Biki said...

Ok, so the post was long, but very very interesting! And I will admit that there was a visit to google to find out what sort of doctor a nephrologist actually is. The ID field sounds like it's both rewarding and extremely frustrating. How is it even possible to have that many different infections going on in one body? It sounds like something out of a novel or sci-fi movie.

Congrats on hearing the rales!! Your shadowing seemed very productive. When is the next round of shadowing to begin?

naturgesetz said...

That must have been fascinating. I'm not sure I could stand being unable to do anything for the people, but I suppose that's what motivates you to keep studying. Anyway, it's a very interesting glimpse into the life of a med student.

Good luck on the exams.

Anonymous said...

Scarlet fever, hurrah! You haven't really lived until you've suffered through about of that illness. What a horrible memory that is.

I've volunteered with HIV+ people before, camps and stuff. It can really be heart-rending seeing what they have to go through, esp, as you point out, with medications whose costs are astronomical and sometimes unaffordable.

cvn70 said...


hey its me really lol and as far as HIPPA hey dont worry there was nothink in that post to worry about

Try always to be general maybe not even mentioning their sex unless its important. Never mention a name, never mention a hospital or clinic name and you should always be okay.

Good luck on the exams and keep those hands sanitized.

take carea nd be safe