Tuesday, September 7, 2010

Block 3: Hodgepodge of Different Tasks

So, what have I been up to for the last few weeks at work? Honestly, it's been a bit of a blur. I finished the MICU on August 19th. Whew! It was rough, but not as rough as it could have been. But it's over, and that's all that matters. Never again will I have to be MICU senior (unless I get aircalled, more about that later). For the first few days post MICU, everything was beautiful- the birds were chirping, the sun was shining, I felt like I had escaped from jail (not that I know what that feels like). But then after less than a week of a normal sleep schedule, I dove into 7 straight overnight shifts. So now I'm just tired. Really tired. People say it takes about two weeks to recover from the MICU. Well, due to the 7 overnights, my two weeks start now so I'll hopefully be feeling good around, say, Sept 21st ;)

So this month, I am on 'elective'. What does that mean? Generally, it means home by 5 pm and weekends off with some free time during most days. From an educational perspective, we get to choose which consult service we'd like to rotate on. There are tons of options including Pulmonology, Cardiology, Electrophysiology (electrical activity of the heart), Benign Hematology (bleeding and clotting disorders), Rheumatology, Gastroenterology, Infectious Disease, etc, etc. I chose to do Transplant Infectious Disease. This specialty focuses on Infectious Diseases that occur in patients who have received organ donations of all kinds: heart, liver, kidney, pancreas and bone marrow. Since the bone marrow transplants usually fall under the purview of Oncology (with some exceptions--> BM txplants are done for some autoimmune problems like lupus), I'm likely to deal with this difficult breed of infections in the future.

Transplant patients are at increased risk of getting all kinds of infections from the common cold to unusual fungal infections because they are on immunosuppresive medicines to prevent their bodies from "rejecting" their transplanted organs. As complex and remarkable as the immune system is, at its core the job of 't cells' and 'b cells' (the immune cells) is to distinguish "self" from "not self". "Self" should be left alone and not attacked, "not self" should be destroyed. Seems simple enough but there are a million ways this can go awry. For example, in many diseases, the body erroneousely thinks that something that is actually "self" is "not self". This is the underlying problem behind most autoimmune diseases such as hypothyroidism, lupus, celiac disease, seasonal allergies and ITP (idiopathic thrombocytopenic purpura, which my family is all too familiar with). Rather than (or in addition to) destroying invading viruses, bacteria and fungi, the body destroys its own cells causing various symptoms from "the sniffles" in seasonal allergies, joint pain and destruction in lupus and thrombocytopnia (low platelets) in ITP.

In transplant patients, we have to manipulate this sense of "self"/"not self" so that the patient does not destroy the new organ which is decidedly "not self". So, to prevent this destruction, or "rejection", we give patients massive doses of immunosuppresive medicines. These meds are pretty darn good at preventing rejection, convincing the immune system that the "not self" organ is actually "self" thus allowing patients to live with their new kidneys, livers, etc. At the same time, though, we confuse the immune system into thinking that things that are "not self" are "self". In other words, bacteria, viruses and fungi are allowed to grow unchecked in the body that would never survive were it not for the immunosuppressive meds. This, of course, is a gross oversimplification but what do you expect from a blog, really?

So this is what we deal with on Transplant ID. The more interesting cases are the unusual bugs like histoplasmosis, aspergillus, mucor, candida which are fungi and molds that never cause problems in "healthy" people but can cause serious problems in the immunosuppresed. We also deal with commonplace viruses that we all have such as EBV (Ebstein-Barr virus, causes mono), HSV (herpes siplex virus, causes cold sores), and VZV (varicella-zoster virus, causes chicken-pox and shingles) that re-activate in the immunosuppressed. Healthy immune system keep these viruses at bay but as soon as patients are immunosuppresed it's like a free for all, a virus orgy if you will, with massive replication causing massive problems such as diarreha, rashes, anemia, meningitis -the list goes on and on.

So this is what I will be working on for part of the month.

Within each elective block, we have various other miscellaneous responsibilities. For example, last week I was on "Nightfloat". Nightfloat is a wonderful system Northwestern has that prevents us from having overnight call on the months we are working on general medicine. Many programs (such as my alma mater, U of C) have a "q4 overnight call" system, which means that the call team (1 resident, 1 or 2 interns) work from 7 am--> 1pm the next day every 4th day. That's 30 hours in a row. Every 4th day. HOW AWFUL!! At Northwestern we only have that greuling schedule in our ICUs because the Nightfloat team does the overnight admissions. Despite the fact that Nightfloat means I work 7 days in a row from 7pm-->7am thus have absolutely no life outside of work, eat, sleep, run...repeat the week can be kinda fun. There are 4 Nightfloat residents admitting new patients and 2 Nightfloat interns who are "cross-covering" on old patients, all hanging out in 1 room all night. You can imagine how loopy we get! I've had some of my best laughs in the middle of the night on nightfloat.

FYI: Definition of "cross-covering": The "cross-covering" interns are the point people for the nurses to ask questions about patients. Most of their calls are really annoying like "Mr S would like to have a bowel movement" (wonderful) or "Ms Z wants a vegetarian diet" (so glad to be woken up at 3 am for that one) but every once in a while it's something important like "Mr X can't breathe" (oh-my-god, I better get my resident for help!). Either way, it's a crappy gig, one more reason being an intern really sucks.)

My third responsibility this month is aircall. This is another good Northwestern system. Aircall is our back-up system for when residents are sick or have family emergencies. There are 3 aircall residents at any one time. This prevents residents from having to rush to find coverage at arguably some of the most difficult times of their lives--calling around to find someone to do your job for you is not something you want to do while you are ill or have to deal with a family situation. I love the aircall system and I have used it for family emergencies and deaths but I do think it gets abused. My personal rule for aircalling during a personal illness is "if you don't have intractible vomiting or diarrhea, suck it up". So, I've worked through fevers, terrible colds, nausea without vomiting, you name it. But I know for a fact I have been called in for lesser things, which sucks. Tough it out people! Save the aircall for family emergencies!

Being aircall is stressful because you are on elective, thus should be enjoying life, but you have this spectre of getting called in hanging over you. The things we get called in for range from clinic (not so bad) to MICU overnight call (terrible, terrible!) and you never know what you're going to get until you get that page.....Keep your fingers crossed for me- my aircall week starts on Friday.

Wow, this post was longer than I intended. If you got this far, thanks for sticking around, I hope you learned something!

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