Friday, June 24, 2011

An Unfortunate Consequence


I was working in the hepatitis clinic, in a public hospital one morning when I was called by my supervising physician who asked me to go to the in-patient unit and see a 25 year old male patient.  My attending had been called by the rheumatology attending who informed him of this particular patient.   I asked a few questions and then hung up.  I finished seeing my out-patients in the clinic and then paged the rheumatology attending. 
“Dr. Andrews, this is Sharon.  Tom (my attending) has told me about this patient you want us to see.  What’s going on with him?”
“Sharon, he’s got chronic hepatitis C, his antibody test came back positive in this morning’s labs.  He was admitted to the hospital last night, due to his having 102 fevers, bacteremia and necrotic lesions on the back of both of his lower legs.  He’s on our service due to the fact that he has medium vessel vasculitis due from the hepatitis C virus.  The back of both of his lower legs are necrotic and basically gone.  He’s going to need surgical grafting, that is, if he is a candidate.  Surgery may not want to do anything else besides their initial debridement done last night, because they will see him as a poor candidate, he smokes 3 packs a day, hasn’t quit using intravenous street drugs and probably weighs about 100 pounds, if that.  He’s also a dumpster diver, he’s lucky if he gets anything nutritious on a daily basis.  Anyway, I’m getting ready to start in-patient rounds with the rheumatology fellow, we’ll be seeing him shortly, do you want to join us?”
“Sure, where are you going to start?”
“We’ll be up on the 9th floor medicine side.  This patient is on 8 medicine.”
“Okay, well seeing that this patient is on 8, why don’t I go up and review his chart, get started on the GI-Hepatology consult for you, and then when you finish with your patients on 9, I assume you’ll be coming by 8 to see him?”
“That would be the plan.”
“Okay, well then I’ll meet up with you on 8, until then I’ll get started on the consult.”
“Great.”

This patient ended up having two of the various extra hepatic (meaning outside of the liver) manifestations of his viral hepatitis.  (see below) Not only did he have bacteria in his blood stream which was due from his having two large and open wounds on his lower legs but he also had deposited immune complexes into his blood vessels in his legs which over time had cut off his circulation.  This had lead to his having necrosis of his lower posterior legs and losing not only the skin but the underlying muscle. 

Chronic hepatitis C can cause numerous extra hepatic manifestations.  These manifestations are due to the virus causing the immune system to become unregulated and it begins to attack the patient’s systems.  These manifestations can include:
Cryoglobulinemia (immune complexes being formed and deposited in various organs/systems, blood vessels)
Lymphoma (a cancer of the lymph glands)
Idiopathic thrombocytopenia (a low platelet count, platelets are used to clot off a bleeding episode)
Auto immune hepatitis (the patient’s immune system begins to attack the patient’s own liver)
Leucocytoplastic vasculitis (small vessel disease, an inflammatory disease of the small vessels where immune complexes are deposited)
Porphyria cutanea tarda (a condition where the patient deposits porphyria in their skin cells)
Lichen planus (a type of skin rash)
Diabetes mellitus (the patient becomes unable to regulate their own blood sugar levels and has to take oral medications and/or insulin to keep the blood sugar under control)
Membranous proliferative glomerulonephritis (a condition where the patient deposits immune complexes in the kidney and over time the patient loses kidney function)
Cardiomyopathy (an enlarged heart or a heart that no longer pumps correctly)
Myocarditis (an inflammation of the heart muscle)
Mononeuritis multiplex (various nerves are involved which have lost the necessary blood flow to survive, usually due from immune complexes being deposited in blood vessels which then are no longer able to give oxygen and other nutrients to the involved nerves)

About 45 minutes later, as I was focused on finishing writing up the consult note, Dr. Andrews taped me on the shoulder.  
“Are you ready?”
“Sure am.  Let me just sign these orders and then give them to the ward clerk to order for our patient in the am.”
After handing off the patient’s chart to the ward clerk, I followed Dr. Andrews down to the patient’s room. 
“Hi, Brian, you remember me from when you were admitted to the hospital through the emergency room last night, correct?” asked Dr. Andrews.
“Yep, I do.”
“You just meet Sharon a little while ago, she works for the GI-hepatology service.  She’ll be the one who will see you in the hepatitis clinic, once you’re discharged.   And on my right, is Dr. Miller, he is the rheumatology fellow this month and will be following you along with the surgical service.”
“Okay.”
“Sharon, I assume you got a good look at the back of Brian’s lower legs?  You saw what surgery is going to have to try to repair?”
“Yes, I did.”
“Well, once he clears out the bacteremia that’s in his blood stream with the IV antibiotics he’s on, surgery will hopefully be taking him to the operating room to debride his lower legs some more, and then put a mesh dressing over them.   Then he’ll have to finish up the two weeks of IV antibiotics before surgery even wants to go and try any sort of muscle graft.”
“Okay, well then I’ve got all of his blood work for his hepatitis C ordered for in the am.  That will give us all of the preliminary information I’ll need.  I can go ahead and also order an ultrasound of his liver.  Then when he is ready to begin his treatment program, which I assume won’t be for quite some time, seeing he’s got quite a bit of surgery ahead of him, as well as drug rehab, then I can order his liver biopsy.”

There are various pieces of clinical information that we need to be able to treat patients with chronic hepatitis C.  A partial list includes: patient’s genotype (there are 11 different ones in the world, within the U.S. we typically only come across 3 of them, genotype 1 (hard to treat), genotype 2 and 3 (easier to treat), viral load (we use 600,000 as our cutoff, anything below this is a good sign that the patient will respond to treatment, above this is a sign to us that they may not respond and clear the virus). 
With the ultrasound of the liver we can acquire the following information: how large or small is the liver, if it’s small then it is probably cirrhotic (end stage), whether the liver has fat in it (which is due to the virus depositing it there), and whether there are any suspicious lesions which could lead us to believe they may have liver cancer (caused by the virus).
A liver biopsy acquires a very minute piece of liver and from this the pathologist can tell us what stage of disease the patient is in.  In other words how much damage has occurred to the liver from the virus.    

“Sounds good to me.  He’s going to be in-house for several weeks, so why don’t you just check in on him every so often and I’ll make sure that you’re informed when we get ready to discharge him so that he can see you on the out-patient side.”
“Sounds like a plan to me.”
“Has surgery been by to see you today, Brian?” asked Dr. Andrews.
“Yeah, they came by this morning.  They told me that if I come back with negative blood cultures by Friday then they will schedule me for the an additional debridement on Saturday morning. “
“Alright, well then I’ll see you tomorrow on rounds.”
With that the three of us left Brian’s room and went back to the nurse’s station.  I excused myself from Dr. Andrew and his fellow and returned to the GI lab to inform my supervising physician of the plan on Brian.
Every so often over the next 6 weeks I went up to the medicine floor and checked in on Brian and read the most recent chart notes on him.  Brian had been to the operating room twice for surgical debridement and they had finally been successful in doing bilateral muscle grafts to the back of both of his lower legs.  He had good circulation and physical therapy was working with him on his ambulation skills. 
Discharge planning had come up with a plan to send Brian to a drug rehab unit where he could work on his addiction to street drugs.  He would be there for at least 6 weeks.  Surgery would be following him in clinic.  So with that in mind I went in and advised Brian that I would see him in 8 weeks in my clinic.  Dr. Andrews had informed me that he didn’t want Brian to have to wait the whole year off of intravenous street drugs before I started treating him for his chronic hepatitis C.  He informed me that Brian’s vasculitis was still active despite immunosuppressive drugs and would remain so because surgery didn’t want them understandably to use prednisone on him, seeing that would affect his healing process.  So the only thing that was going to put a halt to the vasculitis was to treat and get rid of the hepatitis virus.

Brian had a lot of emotional/mental issues that he had to work through.  Not only did he have to address his reasons for using street drugs, but he also had to address his having acquired a chronic viral disease from his illicit drug use.  He had very little, if any, support from friends and family members to help him or encourage him to acquire healthier eating patterns, quite his drug use and stop his smoking.  The brick wall in front of him was immense and would take him quite a while to be successful at overcoming everything in his path towards being healthy once more. 
 
Eight weeks went by and I was surprised when I walked into a clinic exam room to find Brian there.  He was rather talkative and nervous, hobbling around on his crutches.   
“Hey, Brian, how are you?”
Somewhat in a rapid fire speech pattern, Brian said, “Slowly getting better.  I just had my check-up with surgery last week and they cleared me from needing to see them again.  They told me that my muscle grafts are as healed as they are going to get.  I’m still using my crutches to help me ambulate, because I don’t have a lot of strength yet in my legs.  I’m now doing out-patient drug rehab, I finished the in-patient program.  I’ve been drug free now for 3 months.  But I’m still having to deal with my cravings.”
“Well it sounds as though you are on your way to improving your health.  I’m glad to hear it.  You’re scheduled to see rheumatology this afternoon in clinic I see on your patient schedule.  I know that they are going to want you to get started on your hepatitis treatment program sooner rather than later, how do you feel about that?”
“I’m not sure I can handle those weekly injections at all.  It’s probably going to give me flashbacks to my using street drugs.  I’d rather put off my treatment for a couple of months until I’m further into my drug rehab.”
“Okay, that sounds reasonable.  Why don’t we go ahead and schedule your liver biopsy for in 2 months? Then I can see you back in 3 months, and tell you the results of it.  And if at that time you feel you can handle the weekly injections then we can start.  Does that sound reasonable to you?”
“Yeah, I can handle that.”
I went ahead and advised him what to expect with the liver biopsy and then went to go schedule it.  I came back into the exam room to find Brian nervously rocking back and forth on his crutches.
“Are you okay, Brian?”
“Yeah, I think so.  It just makes me nervous to think about doing those weekly needle injections for my hepatitis C, that’s all.  I’ll just have to work through it.”
“Well if you don’t want to do it, that’s okay.  Or if you think it’s too soon, let me know.  Here’s the information on your liver biopsy date and where to go.  So I’ll see you a couple of weeks after the biopsy and we’ll talk about your treatment again then, okay?”
“Yeah, okay.”
With that I said good-bye to Brian and he went to the lab to get his blood work drawn for his rheumatology appointment. 
Three months later Brian was on my clinic schedule but he didn’t show.  I wasn’t surprised.  Dr. Andrews had told me that he hadn’t shown for his last rheumatology appointment either which was six weeks prior.  I went into the computer to check to see whether he had acquired his liver biopsy and he hadn’t shown up. 
Two weeks later I received a page from psychiatry asking me to come up and see a patient on the in-patient unit.  It was Brian.  He was severely depressed, and had attempted suicide.  They told me that Brian had verbalized he was afraid of doing the treatment and was having numerous flashbacks to when he used street drugs.  They wanted me to come to the in-patient side and just explain and teach Brian what to expect.  They were putting him on anti-depressants.  So I went over that afternoon and sat with Brian for a while as we went over again what to expect and that he had the power to decide when he was ready, I was not going to push him into it. 
I saw the attending psychiatrist several weeks later and he informed me that Brian had been discharged, was being treated as an out-patient when he came into the emergency room last week in full code.  He had injected enough heroin into himself to end his life.  

Introduction/Disclaimer

Hello, welcome to my blog about medicine.  I’ve written it for all of the various laypeople out there who need solid information on how to be the best patient advocate they can be for their family members as well as for themselves. 
At no time do I want you (my reader) to assume that the medical information contained in these real patient encounters are meant for you.  Please take the time to discuss any information contained in these stories with your physician or medical provider.  Only with their help can you determine what the best route is for you to take in addressing your own personal health issues.
Please know that I have never used the patient’s real names or given away the locations of the clinics/hospitals I saw them in.  All of the stories are real patients I’ve seen, real scenarios that happened with real endings.   I’ve written about the most interesting, informative patient encounters I’ve been involved in over more than 20 years and counting of being involved in clinical medicine as a physician assistant.  Hopefully this will also allow you to understand what a physician assistant is and what we are capable of doing.  We are as close to being a physician as we can be, without being one, our typical medical training involves an undergraduate degree with 3 additional years of graduate training. 
I hope you enjoy reading the stories, learn from them and use the information contained herein to help you become a better patient advocate for yourself and/or your family members and friends. 
I wish you the best,
Sharon

Wednesday, June 22, 2011

Swimmer's Ear and Then Some

Just the other day I had a patient come into my clinic to be seen for an acute external otitis (external ear infection typically called a ‘swimmer’s ear).   I was working in an urgent/acute care setting that evening, so she wasn’t one of my regular patients I saw. 
I’ll call the patient, Doris.  (real names of patients are never used)
As I walked into the exam room, Doris was sitting on the exam table cupping her left ear with her hand.  She looked at me with a sigh of relief.
“Hi, I’m Sharon, I’m a physician assistant, how can I help you?” 
“I think I have an ear infection.  My left ear really hurts, especially when I touch the outside of it or try to eat, “ said Doris.
“I see.  Well when did it start to hurt?” I asked. 
“Two days ago.  I’ve been swimming to try to lose weight and after my swim on Thursday evening, I went home that night and started noticing that my ear was beginning to bother me.  Then yesterday it really started to bother me, and now this morning I can’t even touch the outer part of my left ear without winching, “ spoke Doris.
“Okay, well let me ask you a couple of questions, then I’ll take a look at it.”
“Okay.”
I went through Doris’ past medical history, the medications she took and her family history.  Besides her hypertension and high cholesterol levels, for which she was on medicines for, she didn’t have anything else that was of concern. 
I proceeded to do my physical exam on Doris and didn’t find anything out of the normal except her left external ear canal, which was quite red and swollen.  No wonder it hurt. 
“Okay, Doris you do indeed have an external ear canal infection.  I need to give you some antibiotic drops to put in your left ear canal twice a day for the next week.  Unfortunately you’re not going to be able to swim until you’re done with the drops in a week.  Your pain should start to resolve by tomorrow after you’ve been on the antibiotic for 24 hours,” I advised her.

Swimmer’s ear is a common problem during the summer months.  Patients want to cool off, they hit the pools, the beaches, or riding their inner tubes down the rivers.  I’ve seen many, many patients with this problem over the years, they forget about the simple solutions to prevent the external ear infections, such as using a hair dryer, or shaking your head from side to side as you are leaning over to the side. 
 
“Let me finish my charting and I’ll give you the prescription for the antibiotics.  You might find it handy when you return to the pool after a week to carry a hair dryer with you.  When you get out of the pool and are changing into your street clothes, take the hair dryer and blow some hot air over your ears for about 15-20 seconds each.  Make sure that the hair dryer is a good 12-18 inches away from your ears when you do this.  By doing this you will blow air into your ear canal and this will dry any remaining water in the canal.  It will then prevent any further occurrence of an ear infection for you.”
“Just a hair dryer is all I need to use after I swim for a few seconds each time?” asked Doris.
“Yep, nice and easy remedy,” I replied. 
“I’ll do it.  I didn’t realize it would be that simple.”
“While you’re finishing your charting do you mind if I use your scales to weigh myself?” asked Doris.
“Nope, go right ahead,” I replied.
As I was charting, I overheard Doris say to no one in particular, “I don’t like going to my own doctor because she gets down on me so much about my weight.  I can just hear her say, ‘now get on that scale!’  She just makes me so uncomfortable.”
I had to reply to her comment.   I turned away from the computer and asked Doris a question.  “Doris, how long have your been fighting your overweight status?”
“Years, I started having problems with my weight when I was a teen-ager, then it just slowly started getting worse.  I never lost the weight I put on after I had each of my two children.”
“Okay, so you’ve struggled with it for many, many years.  Therefore it’s not going to go away overnight or even after several months.  You’re slowly making the right lifestyle changes now that you need to make to permanently lose your weight.  You’re now exercising with your swimming and I assume that you have changed your diet, correct?”
“Yes, I’m now on Jenny Craig.”

Obesity is becoming a huge problem for the U.S. population.  A study done by the Johns Hopkins School of Public Health in 2007 stated that by 2015 75% of all adults in the U.S. will be overweight, and 41% will be classified as obese.

Much of the problem relates to how sedentary we have become as a population.  We love being ‘couch potatoes’, watching TV at night instead of getting out and going for a walk. Our jobs are no longer one in which we exert energy by doing manual labor anymore, instead we have become employees who sit in front of a desk and a computer all day.
 
We all need to change our lifestyles.  We all need to go for a walk, get some daily exercise in, climb the stairs at work, instead of taking the elevator, for instance.  We also need to change our diets.  We need to quit eating all those fast foods and start eating fruits and vegetables with a small portion of meat every day.  We need to lay off of the deserts, stop eating all those snack foods and begin to realize that what we are putting into our mouths needs to be nutritious for us, not just empty calories.

Our problem as a population with hypertension (high blood pressure), heart disease, high cholesterol levels, diabetes would be greatly reduced if not potentially resolved, if we all took into account how our weight plays a big part in our own health issues.    

So, take the first step of many, get out of your chair, go for a walk and then go for a walk every day.  Take the first step of many towards better health, you’ll feel better, your joints will feel better and you will have more energy to do all the things you love!

“Great.  Then what you need to remember it that you’re going to succeed this time.  Once you get down to your ideal weight, don’t stop the exercise program, stay with a nutritious diet, you might want to check in with Weight Watchers and see whether after you’ve lost your weight, whether they have a diet program for those who want to maintain their ideal weight.”
“The bottom line, Doris, is that you need to remember you are not a failure.  Your weight does not define you.”
“Thanks, for telling me that.  I do so try to lose the weight, I know it’s not good for me.  Too many other things get in the way, work, cooking for my husband, housecleaning, you name it.”
“Do you have a support group to help you out and keep you encouraged about it?”
“What do you mean?”
“Well you will probably find it helpful if you have 2-3 friends who will help you out.  Go walking with you, cheer you on, call you once a week, etc.”
“I hadn’t thought of that.”
“Another idea is to have a food journal.  Write down everything you eat, that’s been found to help people lose weight when they actually see what they have eaten every day.”
“I’m doing that.  But thanks for the idea of having friends involved.  Why doesn’t my physician help me out like you just did?  All she does is come down on me about my weight and not try to see how hard it is to lose the weight.”
“Well, I don’t have an answer about your physician.  All I know is that you’re heading in the right direction with your exercising and dietary changes.  Keep up the good work and don’t give up, this has to become a permanent lifestyle change for you.  So take it one day at a time. “
With that I turned back to my computer and finished charting, printed off her antibiotic prescription, handed it to her as I wished her well and exited the exam room.