Rheum vs. ID III

A 25 year old woman presents with a four year history of right ankle ache. About eight months ago, the ankle pain acutely worsened to the point that she could not bear weight on it. She presented to the doctor and an ankle tap showed a WBC count of 20,000, no organisms on Gram stain or culture, and AFB negative. She then proceeded to get a synovial biopsy which showed acute synovitis, not characteristic of rheumatoid arthritis. Nothing was really done at the time and she was sent back to jail where she had been. Several months later, the ankle was still bothering her so rheumatology admitted her for a midfoot deep tissue biopsy and expedited work-up. The other pertinent history is that over the last 8 months, she converted her PPD. Rheumatology then consulted infectious disease for a question of TB arthritis.

Her past medical history, medications, allergies, and family history are non-contributory. She denies drinking, smokes a few cigarettes a day, and has a history of IV drug use. She injects heroin, last use several months ago, but she denies injecting into her ankle. She denies fever, chills, appetite change, weight loss, cough, hemoptysis, chest pain, dyspnea, nausea, vomiting, diarrhea, dysuria, edema, photosensitivity, or rash. She did say she had night sweats.

She was afebrile and her vital signs were stable. Her exam was completely benign except for her ankle which was swollen, tender, and with decreased range of motion (limited by pain). Initial cultures of her deep foot biopsy are negative for all organisms. Her chest X-ray is clear. Labs were significant for a strongly positive ANA (>1:640) and a mildly elevated rheumatoid factor.

The rheum-ID conflict came up over TB arthritis. 90% of TB in immunocompetent patients is pulmonary, and of the extra-pulmonary manifestations, arthritis is uncommon. Furthermore, TB arthritis favors large joints like the hip and knee rather than the ankle. Despite her PPD change, she has nothing going for TB except the vague night sweats. Of course, TB can do anything, but we decided that she did not need RIPE treatment (the regimen for active tuberculosis) until the culture results of the deep tissue biopsy came back.

Nevertheless, rheumatology as the primary team decided to start RIPE. They sent her to TB clinic who wanted to rule her out for pulmonary TB despite lack of pulmonary symptoms and a clear chest X-ray. This was another example of case that was not completely clear cut between specialist services. It was nice, though, for me to review rheumatology as I may not get to do that elective this year.

Poem: Veranda

The veranda is a poem with a silly made-up form, almost a parody. The structure of the veranda is simply this: each stanza needs to mention a piece of summer lawn furniture. Clearly, the number of stanzas is limited by one's knowledge of summer lawn furniture. I jotted this veranda down while on a plane for a trip to Seattle this weekend.
-

Veranda

Out in the veranda when the earthquake souped
the ground, tortilla chips diving into salsa, tomatoes
afray, lawn gnomes like angels thrown into the air, their
stone beards wisp into cotton candy, their gnomey

hands flailing; one gnome impaled in the belly by a flying
patio umbrella, rainbow-like, and a chuckle escapes
my dentures as I imagine missile to helicopter. A
cat's flickering paws, tail of flax, Cheshire smile

no one sees but me. Let me home, I cry, expecting
rubies or shoes and getting popcorn lawn chairs,
chartreuse, taupe, mauve, a seizure of colors
as I fly trampoline-flung into the ground. Cartoon

image: a halo of birds and stars. Lightning crackles
the ground once more, sprinklers whirring, a troubled
leg that won't stop shaking; probably nothing, but what
if it's Huntington's, a rift leaving me adrift, voices aclang.

Rheum vs. ID II

This is a continuation of the case presented in the previous post.

Neurology determined that this was not bacterial meningitis. I went to consult for infectious disease and though we were concerned about septic arthritis, we did not feel that this was a slam dunk diagnosis. Septic arthritis presents with WBC counts into the 100,000s and the most common organisms are Staph and Strep, but those organisms are almost always seen on gram stain or culture. It is so incredibly unusual for the gram stain and culture to be negative (prior to antibiotics) that we didn't feel the most likely diagnosis was a classic gram positive joint infection. The alternative is a disseminated Neisseria gonorrhoeae infection which classically presents as a migrating large joint infection in a young sexually active patient, sometimes with a negative gram stain and culture. We recommended keeping vancomycin for gram positives including MRSA and considering ceftriaxone for gonococcus.

Rheumatology evaluated the patient and agreed that although a septic arthritis was concerning, nothing had "declared itself." The patient did not have fever or leukocytosis. They recommended stopping all antibiotics and seeing what happened clinically. Despite our conflicting advice, the primary team decided to stop antibiotics.

Clinically, she remained about the same; she didn't do better and didn't do worse. Serial taps continued to show WBCs from 40,000 to 100,000, no crystals, no organisms. Blood cultures were negative. Gonococcus swabs were negative. Hepatitis serologies were negative. Strangely, her sugars were elevated (200-300) but HgbA1C was 6.6. We began to consider more unusual infections such as TB arthritis (usually monoarticular, but large joint), rheumatic fever (ASO negative, no other symptoms), Brucella (unpasteurized milk history, but no fever, Brucella serology negative), Lyme disease (no exposure, we decided not to order titers), and rheumatologic conditions (ANA negative, RF negative).

We were stumped. Our differential diagnosis remained atypical presentation of gram positive septic arthritis, atypical presentation of disseminated gonococcal infection, atypical presentation of mycobacteria or fungus, reactive arthritis without preceding GI/GU infection, psoriatic arthritis without skin lesions, and other HLA-B27 seronegative arthritis.

Then pathology came back for a synovium biopsy done by orthopedics. It read "fibrinopurulent material." We went down to review the pathology and it seemed more consistent with infection than an inflammatory process. Yet all the stains for bacteria, mycobacteria, and fungi were negative. Nevertheless, we decided to start the patient on antibiotics (ceftriaxone for presumed DGI). We did not think there was enough to push us to start vancomycin.

Three days into the ceftriaxone and she was not getting better; we would have expected improvement by now. At that time, rheumatology gave in and started anti-inflammatories (naproxen 500mg BID). She immediately got relief from that; over the next few days, her neck pain resolved, her knees and ankle had better range of motion. Although we were stumped, she was getting better. We decided to complete a week of ceftriaxone and continue the naproxen. The only new information was an AP pelvis x-ray which found fused SI joints suggestive of a seronegative arthritis.

At discharge, the ID team still feels this is noninfectious despite the extraordinarily high WBC counts in the synovial fluids. The rheumatology team still thinks it's an infection that hasn't grown out. It's a little unsatisfying, but that's clinical medicine.

Rheum vs. ID I

Over this past month, we've had two puzzling patients whose diagnoses are not transparent. In both cases, rheumatology and infectious disease have been entirely flummoxed and each consult service insists it's a disease of the other. These professional disagreements are not only interesting but also reflect the uncertainty in medicine. The next few posts will all be related.

A 50 year old woman presents with several days of severe neck pain, bilateral knee pain, and left ankle pain. She has had "arthritis" for many years in the past but has never seen a doctor; the flares of this "arthritis" affect her neck and knees but resolve spontaneously. It's never been this bad before. Several days prior to admission while on a trip to Peru, she began having severe headache, neck pain, and joint swelling. She cannot easily move her neck. Her knees both have decreased range of motion to the point that she cannot walk. She denies fevers, chills, night sweats, photophobia, cough, dyspnea, chest pain, nausea, vomiting, diarrhea, or dysuria.

Her past medical history is only significant for joint aches and gastritis. She takes ibuprofen as needed. She has no allergies. There is a family history of "arthritis." She grew up in Peru where she worked in villages. She denies drinking, smoking, and drugs. She recently traveled to Peru but was mostly in large cities. She has no sick contacts. She did drink unpasteurized milk. She has had no odd animal exposures.

On admission, she was afebrile, and her vital signs were stable. She was ill-appearing and refused to move or interact. Her neck had decreased range of motion, limited by pain. She did not have focal neurologic deficits. She had a 2/6 systolic ejection murmur best heard at the upper sternal border. Her bilateral knees were swollen and warm but not erythematous. Her left ankle had a mild effusion. The rest of her exam was unremarkable. Her basic labs were all normal, including her WBC count.

Strangely to me, she was admitted to orthopedics. They tapped her right knee and found 130,000 white blood cells, a sky high number concerning for infection, neutrophil predominant, no crystals. The gram stain and subsequent culture were negative. The left knee was tapped, 90,000 white blood cells, neutrophil predominant, no crystals, negative gram stain and culture. She was started on vancomycin to cover Staphylococcus and Streptococcus as well as cefazolin; I'm not sure what that was covering. Orthopedics then pan-consulted neurology to rule out meningitis, ID to treat the presumed septic joint, and rheumatology for kicks.

Gross

I'm usually okay with most gross things. Over the last year and a half, I've encountered spurting blood, dead skin, extensive burns, intestines, amniotic fluid, scabies (mites), stool, bodily secretions of all sorts. Surprisingly, I've done okay. But today we had microbiology rounds with a focus on parasite vectors and worms. That's a whole different story. It was actually quite cool, in a horror movie sort of way, looking at magnified images of mites, lice, ticks, fleas, and bed bugs. Indeed, I don't think I had ever seen a tick before today. It was pretty educational, but I learned entomology is not my forte. We then looked at whipworms, pinworms, roundworms, tapeworms, and their eggs which are also fairly disgusting. These are more visible to the naked eye, and the microbiology lab has quite a collection of preserved specimens.

Image of Ixodes scapularis tick is in the public domain, from Wikipedia.

Infection Control

One of the other hats of infectious disease is hospital infection control, the study of the epidemiology and prevention of communicable disease in the health-care system. It's one of the often overlooked but incredibly important aspects of hospital medicine. Indeed, this rotation really made me aware of washing my hands before and after seeing each patient since all the patients have an infectious disease. But beyond that, infection control also looks at sterilization, personal protective equipment, isolation of patients, and post-exposure prophylaxis. Especially with the scare of novel H1N1 swine influenza, determining patient isolation and the precautions necessary for health care workers is important. After hours, the ID fellow carries around a needle-stick hotline pager in case someone is stuck by a sharp and needs post-exposure prophylaxis with anti-retrovirals or other medications.

One of the scary historic stories regarding infection control is about "Typhoid Mary" shown above who was a healthy carrier of typhoid fever. Unfortunately, she was a cook and spread infection to 53 people, 3 of whom died. Furthermore, she denied carrying the disease and refused to quit cooking; she was forcibly quarantined by the New York Health Department.

Both images are in the public domain, from Wikipedia.

Poem: Galileo, Galileo

This is an unpolished poem based on a true story.

-
Galileo, Galileo

I hope I never get this page:
Your patient jumped out the window.
They are resuscitating him downstairs.
By downstairs, anonymous meant sidewalk
where this Zeus dethroned, failed Icarus
learned clouds are less dense
and sidewalks denser
than flesh

denser than muscle and bone, all those things
surrounding an organ I do not understand.
For what flit through his brain
that crucial moment,
which images flashed before his eyes?

I talked to him an hour prior
and he asked for an apple.
I did not relay this request to the nurse
or dietician or cafeteria.
I didn't think an apple would have averted suicide
but it was a last meal I denied.

Five children, that's what struck me
though in the debriefing
the man with the piano tie said
sometimes, five children
is five too many.

How did he go through the glass?
Did he ascend, an angel deferred?
Did he dive with purpose
or teeter off the edge
or fall back first, arms spread eagle?

Galileo, Galileo.
He tossed the chair first
then became the chaser
a drink that sobered many an Aristotelian,
changing the course of history.

To be honest,
I wish there was something wrong
the day we met,
wished he had mentioned a shadow
or had a chorus of voices
or a loaded gun in his pocket
For how could it be that there were no signs
that I missed nothing
that fate like gravity, like science and history
finds any response of apology
or guilt wanting.

You wrestle my pager from me,
tell me to go home.

Galileo, Galileo,
Good night.

Applications

The application cycles never cease to end. Like clockwork, every four years we have to update our CV's, ferret out recommendation letter writers, and scribble up a personal statement. It's awful, but it's the way things are. For residency applications, each specialty is slightly different; some specialties really favor early applications while others don't review files until the Dean's Letters are submitted in November. Wading through the process is a pain; while it is convenient to apply to all schools through a single application process, it's not the most user friendly, straightforward, or efficient procedure. I'm not sure how to feel about the "Match" process. Through the Match, one submits a rank list of preferred programs and programs submit a rank list of favored applicants. A computer algorithm will determine the optimal matching of applicant to program, and the result of that computer program is final and binding. It's unusual and strange as no other school or job application that I know of uses this kind of process. But I guess we'll see how things go.

Fourth Year

Fourth year is fantastic. Compared to third year, fourth year really is wonderful. As a third year medical student starting on the wards, I was hesitant and lost; I felt inept and stupid. I was busy trying to learn but didn't know anything. I spent too much time acting rather than becoming. But now (especially after my sub-internships) life is fantastic. I was talking to one of my classmates about this; you can tell who the fourth years are simply by the way they carry themselves. They aren't frequently frazzled; they walk about with an air of composure, perhaps arrogance; they have this false sense of security because they survived the supposed hardest year of medical school. It's kind of funny, and I think I do it too. Indeed, I used to get anxiety before I saw a new patient as a third year; I'd pre-template my notes, scribble down my physical exam findings as I did it, think of things to ask and then fail to ask them. But after a year of delivering babies, trolling the emergency department, placing lines in the ICU, and stitching people up after surgeries, I feel a lot more confident when I see patients; I worry less and care more. The knowledge base is also interesting; I don't think I know much more now than a year ago; indeed I probably knew the most book-medicine right after boards. But third year really solidifies a foundation of knowledge that I haven't really appreciated until now; I realized I learned how to think, organize information, talk the language in medicine, reason methodically, and present my thoughts on the fly. I tackled the steep part of the learning curve during third year, and now things are so much easier. As a result, I have much more time to enjoy with friends; I've been to the ballet, I've been reading, I've been dancing, and I've finally realized why people say fourth year is such a relief.

Adnexal Mass II

This is a continuation of the case yesterday. We cleared the patient from an infection standpoint to go to the operating room. The gynecologic oncology team did an exploratory laparotomy, opening up her pelvis where they found frank purulent exudate, which is very suggestive of infection. They then took out her ovary which had areas of necrosis. The gynecology attending stated that it looked much more consistent with infection than cancer, and then he became concerned that it was tuberculosis. They called us intraoperatively and though we did not think it was TB, we alerted infection control and asked all the operating room staff to put on N-95 masks.

They sent the ovary off to pathology. Several days later, we were called and told that they had an answer. After rounds, we all went down to pathology, a part of the hospital I had never tread. There, we looked at slides under a multi-headed microscope where we saw many histiocytes and filamentous, gram-positive, anaerobic bacteria. Indeed, this was actinomyces.

Actinomycosis most often occurs in the cervicofacial region, but abdominal actinomyces, usually involving the appendix and ileocecal region, is well described. The classic description is an infection that spreads contiguously, ignoring tissue planes. We also noted possibly sulfur granules. There have been many reports of an association with IUD use. Abdominal actinomyces is easily confused with Crohn's disease, tuberculosis, and carcinoma, and most often, the diagnosis is made post-operatively after a laparotomy for a suspected carcinoma. Treatment is penicillin.

Adnexal Mass I

One of my favorite types of blogs is the mystery case; let's see if I can do this well. Some of the details are changed for patient confidentiality.

A 25 year old woman from Mexico presents with nonspecific abdominal discomfort and bloating of several months. She cannot further characterize this pain. Otherwise, she is a G0P0, has an IUD in place, and does not have any fevers, chills, night sweats, nausea, vomiting, diarrhea, dysuria, or vaginal discharge. The physical exam is normal except the pelvic exam where a nonpainful right adnexal mass is palpated. An ultrasound confirms this adnexal mass and shows both cystic and solid components. A CT abdomen also noted this adnexal mass as well as liver hypodensities with central necrosis, lymphadenopathy, and right hydronephrosis.

Concerned for ovarian cancer, the gynecologists attempt to get a diagnosis through a percutaneous biopsy of two liver lesions. Neither lesion shows cancer; they both show inflammatory debris and one lesion biopsy grows out Bacteroides fragilis. Uncertain about the significance of this finding, the gynecologists do not treat her with antibiotics.

They decide that they need an operative diagnosis and two weeks later, hospitalize her prior for an exploratory laparoscopy or laparotomy. At this time, she complains of a cough, but otherwise she is doing well. She is non-toxic and her physical exam is unremarkable. A chest X-ray shows a right pleural effusion with atelectasis. They call an infectious disease consult. Meanwhile, a chest CT shows new peripheral nodular densities in the lungs, several of which are centrilobular or cavitary appearing. An abdominal CT shows that the adnexal mass has grown remarkably in size, and the hepatic lesions are more numerous and larger. We ruled TB out by getting two AFB negative induced sputums. The pleural fluid was tapped and was exudative with 3000 WBCs (54% neutrophils, 16% monocytes, 30% lymphocytes).

We met with the gynecology team. We couldn't think of any classic infection causing this picture, but the gynecologists couldn't think of any gynecologic cancer that appeared like this. Both of us stumped, we wanted an operative diagnosis. I'll save that for tomorrow.

Travel Medicine

Both travel medicine and international medicine are interesting offshoots of infectious disease, and we don't get much exposure. Indeed, I'm not sure what vaccinations most travelers get, and I'm easily stymied when I get asked what diseases are particular or endemic to a specific country. But the more I learn about exotic foreign diseases, the more fun it is to ponder a patient's travel history and guess whether it's related to a diagnosis or not. Especially in San Francisco with such a rich immigrant population, knowing one's geography and associated parasites, fungi, and worms really helps.

In the same way, infectious disease histories sometimes focus on details that I otherwise skip over. The infectious disease doctor likes to know about a patient's pets (or animal contacts) and the specifics of their occupation. Activities that may not immediately seem relevant often reveal an unexpected exposure or risk factor. In this way, infectious disease sometimes is that quintessential differential diagnosis specialty where one's prowess at detective work can make all the difference.

Poem: Poem of Lies

Poem of Lies

There is always a measure of a lie
when I tell the woman I love
she's beautiful
so when I tell you
you're beautiful
you know I mean it.
Love, like butterflies of gossip,
has nothing to do with truth,
only with what I'd like you to know
in the absence of renunciation.
I could say it a hundred ways
in a hundred languages
and you would not hear,
could pluck a thousand petals
walk the staircases of a million seashells
beg ocean wave after ocean wave
dangling from the spool of time
and write lines like a schoolchild.
Here is the first:
you are beautiful
I mean, really beautiful
and in the same way a child collects stones
or a writer collects poems
or a musician collects chords
you collect my lies.

Procedures in Emergency Medicine

I took a two evening elective on procedures in emergency medicine which was lots of fun. The first evening discussed central lines, and it was good to review everything I had learned in my ICU rotation. We also practiced the Seldinger technique on models and ultrasound on each other. The ultrasounding was fairly useful and fun; playing around with the machine is the best way to learn how it works. We looked at internal jugulars and peripheral veins on each other. The second evening was the hands-on cadaver lab where we could practice multiple procedures. Although I had done central lines and chest tubes before, we also did cricothyrotomy, an emergency procedure involving cutting a patient's neck to insert a plastic tube into the trachea (windpipe). This is a really important procedure to learn on cadavers because cricothyrotomies are incredibly rare yet life-saving.

I was also excited to do intraosseous lines and a saphenous cutdown, both emergency procedures to get venous access when an IV (or central line) cannot be placed. The intraosseous line, used mostly in children, uses a drill and made me feel like an orthopedic surgeon. The saphenous cutdown required a lot of fine motor skills to dissect down to the vein and reminded me of vascular surgery. All in all, it was a fun evening which allowed us to practice important emergency procedures on cadavers. Again, I greatly appreciate the generosity of these donors to medical education.

Image of a triple lumen internal jugular central venous catheter. It is in the public domain, from Wikipedia.

Run-of-the-Mill

The bread and butter of inpatient infectious disease so far has been endocarditis, bacteremia, fever without a source in an ICU patient, and orthopedic consults. Endocarditis and bacteremia, especially due to Staphylococcus aureus, often come hand in hand. The management of these patients is usually fairly straightforward, but I think other services like the blessing of an infectious disease attending. Given my attraction to the critically ill patient, I actually like consults for fever in an ICU patient. These patients usually have multiple potential sources of infection, a complicated hospital course, and many confounding factors. Sometimes, the fever may not even be infectious in etiology, and more often than not, we cover broadly with antibiotics, but still, the investigation is interesting to me. Lastly, orthopedic infections make up a lot of our consults. Unfortunately, most of them could be managed easily by the orthopedic service, but they seem to ask for our advice for anyone with a fever or positive culture.

Electronic Health Records II

Paper charts are no better. I know many organizations are resistant to changing from paper to electronic charts, but papers get lost, aren't accessible, are illegible, and take much longer to write. They're not as green; they require storage and medical records staff. They require things to be faxed or copied. To read notes, I have to physically run around the hospital. Paper orders have fewer protections; a computerized order entry system can check whether a medication is stocked by pharmacy or whether a dosage is correct. I know a lot of practitioners hate these "checks" but I think if you get the system right, it can be unobtrusive and improve patient care.

In the end, I honestly believe the companies who should design electronic health records need to be big companies who have successfully released user-friendly high-powered wide-reaching software. For example, Microsoft, Apple, and Google need to enter this field (and to some extent, they already have) because software companies run by physicians have failed to deliver good software. I actually am very partial to Google because of their innovative ideas of putting everything on the internet (ie. docs.google.com). It would be incredibly convenient to be able to access electronic health records from any internet-linked computer; obviously, security would be the big issue, but I don't think it's an insurmountable barrier. Google's focus on speed, the user experience, compatibility, and big enterprises makes them an ideal contender. Furthermore, they already have Google Health, and if they made a foray into inpatient hospital systems that linked to patient-driven Google Health records, this could be ideal for continuity, accessibility, and completeness of charts.

Electronic Health Records I

After seeing the computer systems at different hospitals, I realize there's a lot of inefficient systems out there. I know electronic health records have to do a lot: synchronization of data, privacy protection, compatibility of different interfaces, administrative and billing capabilities, ability to pull up radiology films, etc. But what I see is the user interface and almost every system I've used has been extraordinarily user-unfriendly. Some hospitals don't even have a graphical user interface (GUI); their systems are entirely text-based. You don't even use a mouse. It looks like DOS (the old Disk Operating System from IBM in the 1980s and 1990s). Unbelievable!

Even at UCSF-affiliated hospitals, most systems are unwieldy. There are problems that simply should not exist. For example, I have to click a ridiculous number of times to look at labs and they're not organized logically (why split up calcium, magnesium, and phosphorus? How come all the liver function tests aren't together?). When looking at a bunch of radiology tests, I have to click on one, click back, click on the next one; there should just be a "next" button to move directly to the next film. Furthermore, even the infrastructure is unwieldy. It takes the program at SFGH at least several minutes to open. I can't alt-tab back and forth from internet explorer or word. Some but not all notes are on the system. It's frustrating.

Postage

I thought this was cool; they are German postage stamps depicting four antique microscopes.

Image is from Wikipedia, in the public domain.

Poem: Oxford, Fall 2004

Oxford, Fall 2004

Tell me of her lips, my lover said
and I thought of your words
of high tea philosophy arguments

Schopenhauer wrestling Wittgenstein
how in your fervor you threw coffee
over your shoulder, drenched the barista

of your body pressed against mine
as we ducked into the buttery
the steam fogging my glasses

of the potatoes we ate: boiled, baked
twice baked, mashed, fried
steamed, scalloped, and souped

of the frozen walks along river Cherwell
around Corpus Christi's courtyard
the pelican's eyes saying, "You know better"

of our midnight trysts at the falafel truck
and our midnight dares through broken slats
into Radcliffe Camera after hours

of sprawling on any one of forty-two stairwells
telling stories of our castle Elsinore, your tiger
Japonica, a dragon a plaything, a rocket to Pluto:

"Losing your planethood isn't losing everything"
you said, and I believed you until now
when I can't say any of the things I want to say.

More Continuity of Care

When I first started ICU two months ago, we had a very sad case of a woman in her seventies who got hit by a garbage truck. She sustained an overwhelming number of injuries: multiple pelvic fractures, a femur fracture, a crushed foot, severe skin and soft tissue injuries of her lower extremities, and a transected vagina. It was horrible. She went to the OR for an exploratory laparotomy, to interventional radiology for an embolization of a bleeding vessel, to ortho for fixation of her fractures, to plastic surgery for an amputation of her foot, and to gynecology for repair of her pelvic transection. She was a serious trauma victim and given her age, her prognosis is very poor. Nevertheless, she is a fighter. She's managed to make it through an abdominal compartment syndrome, an E. coli sepsis, a Bacteroides fragilis bacteremia, a bladder leak (for which she got two nephrostomy tubes, a suprapubic catheter, and a Foley), pleural effusions and pneumothorax (she has two chest tubes in), and intra-abdominal fluid collections concerning for abscess. She's a really hardy patient.

Today we got re-consulted for a worsening picture of sepsis. She spiked a fever to 39.2 and her blood pressures dropped to 60/25, requiring a phenylephrine drip. This consult reminded me that I really like taking care of sicker patients; it's terrifying and sad, but I like that sense of gravity and responsibility. We looked at all the sources of infection for an ICU patient and broadened her antibiotics (vanco, mero, fluconazole - she has yeast in multiple locations). I hope she can pull through once more.

The other sort-of continuity of care is an interesting dermatology case. On dermatology, I met a woman with a rare disease called Darier disease or keratosis follicularis, an autosomal dominant disease affecting desmosomes and keratinocytes. It's really severe and debilitating, but it is rare enough that only dermatologists really know about it. Surprisingly, we got a consult on a gentleman who has this disease. He has hyperkeratotic erythematous verrucous-looking plaques with yellow crust and scale over 60-70% of his body. He likely has a polymicrobial superinfections of the soft tissue and is admitted for IV antibiotics. It was very educational for me to see a dermatology-related disease right after my last rotation.

Flow

One of the different things about the consult service is the flow. How busy we are is entirely variable; some days, we have a constant stream of consults or a bolus of consults in the morning and other days, there is just one or two. I like it, particularly because the fellow is great at teaching when business is slow. It's fun to see new patients every day; it's like admitting one or two a day without the nitty-gritty work. While we do follow some patients closely, most consults are work-heavy only in the first few days. We get most of our new consults in the morning and we round in the afternoon. The attending is great about going down to radiology to review films. If I have free time, I work on data collection for a S. aureus bacteremia research study, attend morning report, or look up articles.

Micro Rounds

Every week we have microbiology rounds where we go down to the clinical laboratory and a resident walks us through interesting cases. It reminds me how much I've forgotten since second year. As she talked through the various types of agar, the antibiotic tests (like the optochin disc), and gram stains, I had vague memories of how I once knew these things. It's an odd thing to say, but I miss that knowledge even though it's not too pertinent to what I do on a day to day basis. So I had a good time learning about obscure tests and the morphology of strange bugs.

Image is of S. aureus gram stain, from Wikipedia, shown under GNU Free Documentation License.

ID

My next four weeks are on the infectious disease consult service at SFGH. It should be very educational and a lot of fun. Being on a consult service is entirely different than my last few months and it's delightful. The cases we get are interesting and challenging. Primary teams really appreciate our input. There's less busywork and the hours are more flexible. There's a smaller body of information to master. I tend to like depth of knowledge over breadth and that fits this rotation. The team is made up of a fellow, two residents, and two students. We get a lot of independence in seeing consults but the fellow and attending make sure our recommendations are solid. There's a lot of time for teaching. This will be the rotation where I actually learn my antibiotic spectra.

Writers' Conference

The Napa Valley Writers' Conference was an inspired experience. It was beautiful, really. It was one of the busiest and most tiring weeks I've had in a while, as exhausting as a week on call in ICU. But it was so much fun, so fresh and exciting. I was able to go under the auspices of a Healing Arts Poetry Scholarship; the donor is a poet who attended the conference in the past, and I really really appreciated the opportunity.

Writing a poem a day is tough. It saps all my creative energy but it was so rewarding. I was really pushed to my limits, and the prompts challenged me in ways I could not imagine. "A little learning is a dang'rous thing; / Drink deep, or taste not the Pierian spring" (Alexander Pope, Essay on Criticism). The other writers in the workshop were outstanding; I was constantly impressed and inspired by the things I read. The diversity of the poetry was astounding; the forms (pantoum!), the images, the language, the themes. Our poetry confronted assumptions, dared lines of taboo, delved into the mysterious, frightening, and rancid. The participants ranged in age from 20s to 70s, from the Renaissance man retiree to the war veteran to the art historian to the MFA student.

Even beyond the daily workshops, I learned a whole lot about craft and art from the daily lectures. I got a book list. I loved the evening readings. I found poems and stories. I met people. I ate fantastic food (the school is a culinary school). I had an amazing host family. Napa is beautiful. I had a fabulous time. Onto the next adventure!

Poetry in Medicine

I made a delicious find today. In an article by R Brian Haynes and Graeme A Haynes, "What does it take to put an ugly fact through the heart of a beautiful hypothesis?" published in Evidence Based Medicine 2009;14:68-69 (you know, light reading), the authors cite a poet! They quote Samuel Johnson, "the chains of habit are too weak to be felt until they are too strong to be broken." They also cite physicist Max Planck, "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it."

I enjoyed this article because it entertains a poet when I just spent a week immersed in poetry, and because the quotes are fascinating. Why are we so stubborn? The article discusses the fact that multiple large randomized studies have shown tight glucose control in patients with long-standing type 2 diabetes is not beneficial. Does that surprise you? It surprised me; I've had so many clinicians focus on hemoglobin A1c that I was shocked to find that the evidence is not there. In the ACCORD, ADVANCE, and VADT trials, tight control did not lower overall mortality, CV-related mortality, stroke, amputations, or clinical (as opposed to surrogate) microvascular endpoints. Hemoglobin A1c doesn't matter as much as most people think it does! We should instead be focusing on cardiovascular risk factors. Sadly despite overwhelming evidence, things are so slow to change.