Week 6 of Immersion

My 6th week started out well. Dr. Goodman and I went on clinical rounds in the morning on Monday. I was able to see quite a few interesting patients. The second case I saw was a patient that had seropositive rheumatoid arthritis that was diagnosed quite a few years ago. She was first given some methotrexate (the gold standard for RA) and told to come back a few months later. However, she hadn't been back for about a year, so quite a few doctors were concerned about her. To everyone's surprise, the patient had stopped taking almost all of her prescribed medications for her RA. The patient claimed that she was feeling much better and had almost no physical signs of having RA. This was a good sign for the patient, but the doctor was concerned that the RA would come back very aggressively since she stopped her medications; RA very rarely remits completely in the long run. They decided to keep a close eye on her for the next few months, but did not decide for her to continue to take the RA medications, at least right away. The doctor just cautioned her to start taking the methotrexate again immediately if she had any more future RA flareups. This sort of stuff always surprises me; it confirms that patient compliance is a very real issue for RA and other types of arthritis because of personal, religious, fear related reasons.

Another case I saw was with a patient that exhibited many types of diseases at once, including diabetes, RA, OA, as well as a few others. The diabetes was causing her nerve pain that was complicating things somewhat. The patient was originally diagnosed with just OA in the past, instead of RA, but the doctor was convinced that the patient exhibited some sort of combination of the two. The doctor saw some tell tale signs that pointed to inflammatory arthritis (RA) in her wrists (synovial thickening, inflammation, swelling) and feet (same). He decided to prescribe her some RA meds to help with the pain and inflammation. For personal reasons, the patient refused to take prednisone (a steroid) so the doctor had to prescribe methotrexate instead. The prednisone would have had almost immediate effects if there was RA present, and it also leaves the body fairly quickly. This would have helped confirm RA without any side effects. However, methotrexate  (as well as most other RA drugs) takes weeks to take effect and last for relatively long periods of time in the body, which leave patients susceptible to side effects if not managed properly. Hopefully she really does have RA so the methotrexate will be able to help her in the long run. 

I went to the CAP clinic again this week but nothing really happened because the patient did not show up. There was a presentation about various inflammatory diseases though which was pretty cool. 

On Wednesday, Greg (my surgery buddy) and I went to the burn unit on the 8th floor, and by chance, ran into residents on their rounds. We joined them and saw some interesting things. One of the first things we noticed that most of the burns were caused from spilling hot/boiling water on themselves, or by playing with fireworks/fire. We also ran into a very belligerent patient that was busy cursing everyone off because he wanted to leave the hospital really badly. That was interesting. Greg and I were able to go into the wound dressing room and see a patient badly burned on her stomach and legs. It was rather scary to see someone with very little skin left in that area, but it was also very interesting how they treat such wounds. Most of the times, they soak the wounds in saline to keep the wounds from drying out (they heal better wet). If the burn is bad enough, the patient will have to get a skin graft. Another medicine that they use periodically is Silver sulfadiazine, a sulfa drug, is used to prevent and treat infections of second- and third-degree burns. It kills a wide variety of bacteria. Many of the patients that have severe burns suffer from "burn shock" which is a systemic reaction to a traumatic injury (the burn). It causes widespread vasodilation and neutrophil exudation, as well as increased blood pressure. Burn shock is serious and can lead to a wide array of systemic organ problems if not treated properly. 

Greg and I also went to a brain surgery (craniotomy with a brain tumor removal) on Wednesday. Overall the procedure seemed straight-forward: the surgeon (Dr Schwartz in Neurology) made an incision in the skull, then used a dremel tool like instrument to remove a circular piece of the skull so that they could access the brain easily. Once the skull was open, they used a bipolar forceps to cut through the dura mater of the brain to get to the tumor. This instrument was vital because they needed to cauterize the brain tissue (and the tissue around the brain so they wouldn't have any bleeding). Residual bleeding in/around the brain would be very bad. They used some imaging devices (including ultrasound to locate the tumor), which was very close to the base of the skull. This was very lucky because surgery deeper in the brain would have been very risky/fatal. They kept using the bipolar forceps to cut through actual brain tissue around the tumor to remove it and it was successful. The coolest part was seeing the brain pulse every time there was a heartbeat.