Infectious Disease

One of the perks of emergency medicine, OBGYN and surgical rotations is wearing scrubs to work. Between these specialties and vacation it has been a year since I last wore a dress shirt and tie on my rotations. Despite being a little less comfortable, it brings a different sense of professionalism to the game.

Avoiding Disease

Currently rotating on a medicine specialty, infectious disease, I am learning more than ever before, the importance of antibacterial, antifungal, antiviral and antiparasitic medications. I knew there was a lot to know before, but I am now reminded of that fact where it counts, at the bedside. Every day we round on patients who have serious infections including tuberculosis, HIV, meningitis and more. When the patient's infection fighting army can no longer handle the battle, we are called in to bring the reserve armory. Donning special masks, gowns and gloves protects both the patient and ourselves from the exchange of harmful bugs during discussion and examination.

Washing hands is a necessity and stethoscopes are cleaned routinely on this service. If we are not careful, we can be the source of somebody's newest infection at which point it doesn't matter what your tie looks like -- keeping it secured is not a bad idea so it's not dragging through the patient's wounds and dressings. Medicine is a lot like figuring out a good puzzle, both in making a diagnosis and providing the right treatment regimen. Infectious disease aims to find the perfect medication for the job so we are not firing shotguns at thumbtacks every time building resistance to the arsenal we have available. It is a thought provoking field that can have a significant impact on patient outcomes as long as we don't let the disease bug them too much.

Question of the Week

Which of the following drug classes is responsible for both nephrotoxicity and ototoxicity?

A. Carbapenems
B. Penicillins
C. Tetracyclines
D. Aminoglycosides
E. Quinolones

Answer & Explanation

Life as a Patient

Finally nearing the end of my hospital stay, I have gleaned a great deal of information and experienced my share of ups and downs. Surgery was a difficult experience as it left me with pain, wounds, and the after effects of anesthesia. Being in the ICU with all of its high-tech glory was much less fun than I remembered from rounds.


Post-Operative Recovery

Fortunately, I was able to avoid catheterization. Nonetheless, the anesthetics had a long lasting effect that disturbed both my gastrointestinal and urinary tracts. Every time I tried to drink fluids, my stomach would have nothing to do with it. I had to keep the emesis container within reach as there was no way of judging how my body would react. It was more annoying than anything as the cottonmouth was rather unpleasant. Between medicated naps and side aches from my freshly placed chest tube, all I could do was wait for the anesthesia to wear off with my barf bag in hand. Learning to adjust to my new wounds and pains was going to take some time, and all I could do was wait. As the clock rolled, I became hungrier and dared to try solids. It tasted good, went down well and sat well...but only for 10 minutes. It was then that I wished I had an emesis bag the most; a simple device I could put on and forget about. Luckily, it became easier to hold the food in and now I had to get my bladder to cooperate. With some serious concentration, faucets running and a friendly coaxing from my visitors, the bladder situation was overcome in due time.


Little did I know that the next few days would be worse. Inflammation, muscle aches, tubes, wires, medications and the list goes on. Now I was starting to understand what my post-operative patients had been experiencing. From one unpleasant experience to the next, I was now on the doctor's schedule awaiting instructions and decisions. My job was to report any problems, stay attached to all my wall connections, exercise my lungs and generally get better. I was happy to hear I was the most stable patient on the ward, which was to be expected as I was also the youngest. The TV was boring, my neighbor's moans annoying and the food not always appetizing. Getting up and walking around the unit was the most enjoyable activity I participated in during my stint. Something we so easily take for granted had now become the highlight of my day. At last discharge is in sight and I can soon recover in the comfort of my own home. This experience, however, has made a significant impact on my perception of health care and the way I intend to approach my future patients. What a great way to spend my vacation month.

Question of the Week

As a new patient on the surgery ward you are asked by the dietitian make your next meal order. Which of the following will have the worst effect on your health and recovery?

A. Turkey roast with mashed potatoes and broccoli
B. Chicken fingers and French fries
C. Meatloaf with mixed vegetables and a dinner roll
D. Shrimp pasta alfredo with garlic bread
E. Chicken salad wrap with clam chowder soup


Answer & Explanation

Rehabilitation

With great power comes great responsibility. Physicians are among some of the highest educated individuals and yet they are at an increased risk for drug abuse and addiction. Despite their "power", there is a responsibility to lead the way in safe practices.


Medicinal Pitfall

Employment in an environment where medicines are routinely used and available can have deleterious effects on clinicians and other health care providers. Studies have been performed to learn what fields of medicine are at greatest danger of drug abuse and the results usually show increased potential in those that distribute medications frequently. In school we are taught about the signs of addiction, where to seek help if needed, and tactics to overcome the problem. Despite this training, many physicians become addicted as a result of stubbornness, pharmacologic education, and ease of access. Check out some of these addiction facts that may shed a different light on drug abuse.

During a rotation I was surprised to work with a physician who openly discussed his past history with pain killers. He told me that the rehabilitation program he finished was one of the best things to have ever happened to him. For a long time he was in denial that there was even a problem until it interfered with his job and the patients he treated. Some addictions may seem minimal, but the psychologic drive to obtain more is very powerful. Chemical impulses can make even the most mundane stimulus phenomenal.

Addiction can happen to anybody. Fortunately, there are resources available for those who want to find freedom from chemical dependence. Whether it is a private facility, land-based hospital program or an online resource like this Vicodin rehab guide, help is available. As for physicians, most are able to keep their licenses and continue the career they have established once rehabilitation is achieved. Sadly though, it continues to be a problem. We may never know the problems others are facing, but if they come to us for help, wouldn't it be nice to have the right tools?

Question of the Week

A 35-year-old woman is found unconscious in her apartment next to an empty bottle of pills. She is brought to the Emergency Department and given flumazenil, and shortly thereafter regains consciousness. Which of the following drugs did she likely ingest?

A. Diazepam
B. Eszopiclone
C. Hydromorphone
D. Oxycodone
E. Zolpidem

Answer & Explanation

Treatment Options

The urgent care has its fair share of injuries and acute illnesses of which infections are common. It came as no surprise that my precepting physician asked me the best antibiotic treatment for specific infections. Although slow on the start-up, by the end of the month I was right more often than not.

Treatment Modalities

Bacteria have been known to take over our illness for centuries. The fight to halt their progression is still in its relative infancy as companies develop the latest antibiotics to cover certain strains of bacteria. Recently, the war against these microscopic armies has faced some retaliation via mutated strains that have developed resistance. One well known suspect is the staphylococcal organism responsible for Staph infections. Growing resistance has required a new approach to treating these infections. Despite having an arsenal of antibiotics for treating infections already in progress one company, Oasis Advanced Wellness, has a line of products that are intended to augment the immune system and avoid illness in the first place.

I was recently introduced to Oregasil, an oregano oil, that claims to have natural antibacterial properties. Its chemical component carvacrol not only inhibits the growth of certain bacteria, but it is said to taste like pizza! When was the last time you took medication that actually had a good taste? In laboratory studies, this compound was reported to be comparable to the standard antibiotics streptomycin, penicillin and vacnomycin. It is very unlikely that your doctor will prescribe a product like this, but is good to know that such formulations exist for those who prefer the natural approach medicines.

Another interesting product they offer is their Bio D-Mulsion supplement. There is a growing percentage of people who are deficient in Vitamin D. Usually we consume it through our diet, but the largest amount is actually obtained through our skin when we are exposed to the sun. For those who do not get adequate amounts of ultraviolet radiation they are at risk for health complications from Vitamin D deficiency. Thus there truly is a place for supplementing this crucial vitamin when not obtained naturally. Among its benefits, Vitamin D is known for strengthening bones, improving cardiovascular integrity, and boosting immunity. When considering your overall health, start with the basic vitamins and minerals and you'll be on the right track.

Pimped Question of the Week

A patient comes to the clinic with a 6cm, indurated, and raised lesion under the skin of the axilla that is warm, tender and erythematous. They state that they were bitten by a spider while they were sleeping, but did not see it upon waking. What is the most likely organism in the lesion and what is the initial recommended treatment?

Mangosteen Juice

Every now and then I have the opportunity to investigate new products on the market. With energy drinks in every store and super juices making their way to the shelves, our beverages can get a bit overwhelming. The makers of Xango, a competitive nutritional fruit juice company, have developed the recently popularized mangosteen juice.

The mangosteen fruit comes from Southeast Asia and has no relation to mangos. It is a small purple fruit about the size of an apple that has a white tart core. Chemical analysis suggests the fruit contains various xanthones and tannins which may have anti-cancer properties in addition to being an anti-fungal, antimicrobial, and anti-inflammatory compound. It is no wonder that mangosteen juice has been used medicinally for generations.

Although this post has been sponsored by Xango, it certainly sounds to be a healthy alternative to the growing energy drink brands that boast more caffeine and sugar than your mother is willing to give you. As with any medication, too much can be a bad thing. Recommendations suggest smaller doses to avoid sedative or abnormal clotting effects. I assume it is for this reason that Xango promotes mangosteen juice as a supplement. So if you ever get the chance or have already tasted this unique blend, leave a comment and let me know what you think.

The Immune System

Perhaps the denouement is behind us and we are finally on the down turn of coursework for the year. Getting out while the sun is still in the sky and having understandable lectures is a nice change for the new spring season.

Immune System

We have started our coursework in Immunity which at first seems a rather simple subject. It's not until you learn about the variability and diversity that exists when it becomes very complex. Sometimes I wonder why my immune system is just not performing so well. Does anyone know how to treat chronic rhinorrhea? Perhaps when school is out it will cure itself.

The immune system has many components that together provide a healing response to invasions. Having a good knowledge of individual parts will simplify the learning process of understanding how they interact to function efficiently. Although it is good fun learning how it all works, experiencing this process is anything but fun. Fortunately, vaccinations are available to help ward off possible infections.

Resistant or mutant strains of viral and bacterial organisms can prove to be chaotic. The common cold and flu are results of this phenomenon as well as more serious illnesses. Despite our best efforts to enhance the immune system with pharmaceuticals and exercise, it will still have the occasional bout of weakness leaving us in the proverbial pits.

Creative minds have made a variety of infectious agents available for purchase with an added sense of comfort and wit. Check out these giant microbes.

Clinical Corner

Antibiotics

Physicians prescribe antibiotics to eliminate infection. A growing concern is the resistance that develops when patients do not finish their prescribed antibiotic regimen or take it as prescribed. (Some of the bacteria that is not killed may not be susceptible to the specific antibiotic.) This leaves a window of opportunity for bacteria to alter its response to drugs creating a new strain that is more resilient. If this continues to occur in the general population, antibiotics may not work on general infections causing severe complications in public health. The moral of the story, take your antibiotics the way your doctor prescribed them.

Financial Pill Popping

With a new year comes new policy that may have significant change in how future physicians practice medicine. The Pharmaceutical Research and Manufacturers of America (PhRMA) has adopted a new code of conduct that goes into effect January 2009.

Prescription

Making drugs to fill prescriptions is a difficult task requiring years of research, money, and physicians who will prescribe them. A large sum of money is used to buy cheap pens, "free" lunches, or even more lavish gifts that entice clinicians to write a prescription for the latest wonder drug.

PhRMA has revised their code of conduct to put an end to the handouts among their distributing members. Freebies would otherwise raise the ethical question, "is my doctor prescribing this for my best interest or theirs?" Since handouts cost money, drug companies have to increase the cost to the consumer to pay for them. Why not spend the money to produce better pharmaceuticals through well funded research using the money allocated to the 'perks' column in the budget?

Medical students and practicing physicians alike will have to adjust to drug reps without cheesy stationary and edible giveaways. Perhaps the students will be fortunate to never know this ethical dilemma. Although the code attempts to curb the compensations, pharmaceuticals still remain a business that will get money in its pockets any way it can.

Clinical Corner

Blood Donation

After years of putting it off, I finally donated my blood to help the cause and it just so happens to be the National Blood Donation Month. It cost me one hour, one pint of blood and a couple signatures. In return I received one hole in the arm, a purple bandage wrap and the opportunity to help treat and potentially save the life of a patient as a medical student. Blood banks are often in great need of donors as so many patients require transfusions. If you are looking for a great way to serve, consider donating blood and helping those in need.