Penicillin desensitization

I spent Friday morning in the ICU for a penicillin desensitization. Sounds exciting, being in the ICU, but it was actually a lot of sitting around, doing nothing but talking to the patient. It takes place in the ICU so everything is there in case the patient has an allergic reaction (which is kinda expected; the reason why he needs to be desensitized is because he had a reaction in the past). Fortunately, he didn't this time. Like most things in medicine, boring is good.

Penicillin desensitization isn't something that's done all that much anymore, because there are so many other antibiotics that can be used for infections; however, for some infections, such as syphilis, penicillin is by far the best choice, so if you have a patient with a penicillin allergy, you desensitize them in the ICU and give them penicillin.

The way desensitization works is that after everything is set up in the ICU (EpiPen in the room, etc), you start with a very, very small dose, and then if everything goes well, there are eight more injections with increasing doses, separated by twenty minutes. The whole thing takes almost three hours (160 minutes), and then you keep the patient in the ICU for another hour or two after the last dose (which is a full treatment-sized dose) to continue to monitor for allergic reactions. So there's something to do (which takes two minutes) every twenty minutes, and the rest of the time is spent waiting and watching and chatting with the patient (and watching ESPN, because that's what people do during March Madness).

We spent most of the time talking about careers, of all things. The patient is a lieutenant in Navy intelligence, working in MTAC (yes, the real MTAC... it is not a fictional creation of NCIS). His orders are up in January 2011, so we talked about what he wants to do next. Since he's going to be up for promotion to lieutenant commander by then, he wants to deploy to Iraq or Afghanistan (outside of the medical corps, there are boxes that need to be checked for promotions); the problem is, he's HIV positive and therefore not sea-worthy (we say 'non-deployable' in the Army). You can remain on active duty with HIV, and like all medical information, that status is classified medical information, but when it's time for promotion boards, the question does get raised about lack of overseas duty. Fortunately for the patient, he did deploy and have sea time before he became HIV positive, so that shouldn't be an issue for this promotion board, but he does know that he won't make commander, so he's planning on getting out at his twenty-year mark, which is in seven years.

In all, chatting with a patient while doing absolutely nothing isn't a bad way to have to spend a morning. And then I spent the afternoon being enrolled as a healthy control in an asthma study, so it was a very low-key Friday. The hardest part about the whole day was getting skin tested for allergies (I'm apparently allergic to birch and cottonwood pollen; who knew?). As my surgeon friends tell me, this shouldn't even be allowed to be considered an internship, because I hardly ever have to do any work.

And back to the grind

Well, after many hours of travel on Sunday, I arrived back home on Sunday night, only to have to go back to work at WRAMC on Monday morning, to begin my Allergy and Immunology rotation. Fortunately, it's a pretty easy rotation, so that helps ease the pain of being back somewhat. In fact, it's even easier than my Allergy and Immunology rotation at Tripler last year, because there are fellows here (completed their residency, now getting advanced training in Allergy and Immunology), so I essentially just follow them around.

The first patient I saw on Monday was a two-year-old girl who suffers from maternal hyper-vigilant syndrome--pretty much, there's nothing wrong with her, but her mother thinks that she gets sick more than two-year-olds are supposed to, so she's being worked up for an immuno-deficiency syndrome. I'm pretty sure everything will come back normal.

Nothing too exciting on Tuesday or Wednesday, just the standard allergic rhinitis and hives. Today, one of the allergists at WRAMC was giving a lecture on immunology and occupational asthma to the second-year preventive medicine residents at USUHS (working on their MPH), and she invited me along. Of course, by the time I got back to WRAMC, all of the fellows were done seeing their morning patients, so I didn't really have to do except work on my application for a Virginia medical license (we have to be licensed; it doesn't really matter which one, and Virginia is one of the easiest and cheapest) and took off early to take some of the paintings I bought in Peru to the framing shop, where I spent an arm and a leg to get them framed. They better look pretty good when they're done.

Done with the rotation!

Today was the last day of my research rotation (I'm still in Peru; not leaving until early Sunday morning, but all I have left to do is hang out in Lima and spend money I don't have at the Inka Market). It was a pretty low-key day; all I did was give my presentation. Here's the title slide:

Both LCDR Maves and Wes (the Georgetown student) chuckled at the little bugs at the bottom. So, in case you can't tell from the title, I focused my research and my presentation on entomology (the study of bugs, not the study of language--that etymology) and its role in preventive medicine, starting with the history of diseases carried by bugs in the military, with a healthy amount of information about MAJ Walter Reed, because no self-respecting Army preventive medicine resident can do a project that has anything to do with bugs without talking about MAJ Walter Reed.

So that was that. As I was filling out my evaluations and preparing to email the presentation to my program director, though, I realized I never turned in a research proposal to her (supposed to be done one week before the research rotation begins) because I never filled one out. So I did that this afternoon, too, and amazingly enough, I did everything from my proposal during this rotation. I'm just that good (filling things out retrospectively doesn't hurt, though...).

Now I just need to figure out what I'm going to do tomorrow that won't end up costing me another few hundred Soles... (BTW, Mom, I found a painting I think you'll really like. Happy birthday. You'll get it a week after our birthday, when you and Dad come visit).

Neurologic Institute

Sorry about the delay in posts... my computer wasn't reading my SD card, so I couldn't get images from my camera to the computer, and I didn't want a bunch of posts with "and I'll get you the pictures later" all over them.

On Monday, we took a field trip to Instituto de Enfermedades Neurologicas, which is a neurology hospital where they do a lot of treatment and research on cysticercosis, a parasite (worm) infection that can travel to the brain. Most people, surprisingly enough, can have hundreds of cysts and not have any symptoms worse than headaches, which is how they remain undiagnosed long enough for them to have hundreds of cysts.

On site, they also have a museum of brains, with a few walls of specimens of brains with various diseases:

And here's a close-up of a brain with neurocysticercosis:

They also had some healthy specimens, including this one of the central nervous system:

So that was Monday. On Tuesday, we went to Instituto Alexander von Humboldt, which is a tropical medicine hospital. In the morning, we sat in on Leishmaniasis clinic (parasitic infection that causes open ulcers on the skin--got a lot of press in the early days of Iraq, when troops were being MEDEVACed with Leish after getting bitten by sandflies while they slept in the dirt), and then we rounded with one of the attending physicians, who showed us some very interesting cases, including a woman who complained of facial swelling, pain, and "worms coming from her nose". They thought she was crazy, then they actually saw maggots coming from her nose. A fly had flown up her nose and laid eggs, leading to an infection called myiasis (yes, maggots coming from the skin actually has a name). Disgusting.

Then yesterday was spent working on my presentation on Bugs of Military Significance, which is what I'll also do today. Apparently, people want to see something come out of this rotation... apparently, they aren't sending me to Peru just to sight-see for three weeks. Who knew?

Bus tour of Lima

Yesterday, a couple of us (Wes, the Georgetown med student; the vet tech; and myself) decided to do the touristy thing and took a double-decker bus tour of Lima. The tour started at Parque Kennedy, and before you ask, yes, it is that Kennedy. There's even a bust of him in Parque Kennedy.

Apparently, Miraflores is the sister city of Pensacola, FL. Why that means they need a bust of JFK, I have no idea, but there it is. There's also a statue of John Lennon in another part of town, so I think the Peruvians just like statues.

Anyway, driving around Lima, in Lima traffic, on the top of a double decker bus is a bit of a harrowing experience. This is definitely not the worst traffic was, but I want you to take note of the open manhole.

Although Lima is, overall, a pretty dirty city, they do have some nice architecture and whatnot. Here's a picture of what I think would roughly translate to the capitol building.

And this is the monastery San Francisco (as in, for St. Francis, not the city in California), which I think they were saying is the oldest Franciscan monastery in the Western Hemisphere. The catacombs are also located here, and for about two centuries, (1500's-1700's) they buried quite a few people here. When the catacombs were excavated, they found the remains of over 25,000 bodies.

And here's a random shot of a hill that somebody decided to paint a Peru flag on.

So that, and more shopping at the Indian Market, was my day yesterday, and today, I spent a good deal of my time at the hotel (by the pool, for a good bit), working on my presentation, which I'll be giving on Friday. I'm doing it on the roll of entomology (study of bugs) in preventive medicine, briefly discussing the history of vector-borne diseases on military populations (with a few slides dedicated to MAJ Walter Reed), the Army regulations on insect control, ongoing research projects at NMRCD-Peru, the role of bugs in the deployed setting (malaria, Leishmaniasis, and also the sleep deprivation/psychological impact of being surrounded by bugs and giant spiders... Jason, if you have any thoughts on the matter, I'd love to hear them), and directions for future research. In all, it's supposed to be a 30-45 minute talk, so we'll see how that comes along.

Hospital Dos de Mayo

On Wednesday, one of the doctors took me and a fourth year Georgetown student who's down here as well (Navy HPSP) to Hospital Dos de Mayo (second of May; one of the major battles against the Spanish back in the day), which is one of the public hospitals in Lima and a major teaching hospital for medical students and residents.

The main thing we did there was listen to morning report (well, listen to that doctor translating morning report for us), which was about a few cases of HIV patients. They have a lot of the same problems with HIV patients that we have in the States--mostly, people not being compliant with their medications, and thus getting complications--but they don't quite have the same lab capabilities or treatment modalities that most hospitals in the States have. It was interesting to hear about how some of their treatment guidelines differ because of this.

One interesting thing about the hospital and associated clinics is that they pay for lab tests at a window (as opposed to getting a bill in the mail later). So they have this large sign that has all the prices listed for various labs and tests. I know you can't see it well here, but all the prices are fairly nominal, at least compared to our prices. For example, an EKG costs S/15, which is about five dollars; an echocardiogram is S/60, which is about $20. There's no way you could get an echo for $20 back home. I don't think the few minutes it takes the cardiologist to watch it and declare it normal would even be that little, not to mention the technician's time or the actual procedure costs.

On the grounds is also the crypt of Daniel Carrion, a national hero in Peru, especially in medical circles. When he was a medical student, he proved that systemic (throughout the body) and cutaneous (on the skin) Brucellosis were caused by the same bacteria, by injecting himself with pus from a patient's cutaneous Brucellosis sore. Unfortunately, he died of his little experiment, which just proves one of my points--if you suspect something is going to kill you, don't do it.

So that was my morning on Wednesday. Then I spent the afternoon hearing about research in parasitology (mostly malaria) and virology (mostly dengue) going on in Peru, and yesterday spent the day in the virology lab, learning the various techniques and tests that they do.

Pre-Incan ruins, and back to work

Yesterday I went to Huaca Pucllana, which is a temple built to the water and sun gods of the Lima culture, a pre-Incan culture of around 800 AD. In fact, before the temple was excavated in the 1980's, nobody had any idea that this culture existed. When the Spanish conquered the Incans, they obviously learned about the Incans, as well as the peoples that the Incans had previously conquered, but before that, there weren't really any records. Anyway, before excavation, this was just a dirt hill in Lima (there were houses and whatnot built over parts of it as well. Here's what it looks like today (with some excavation still in progress):

I like this next picture, because it's a good visualization of these very old ruins amidst a fairly modern city. It's actually right in the middle of Miraflores (the district in Lima where my hotel is), and was walking distance from the hotel.

Here's a picture of a fairly famous dog in Peru. Not a famous breed of dog, but a famous dog. Apparently, the Obama's search for a hypoallergenic dog was worldwide news (I'm rolling my eyes), and the government of Peru offered this dog to the Obamas (it's about a year old now, so it was just a puppy then), because as hairless dogs, they're completely hypoallergenic. Obviously, the Obamas picked a different dog, and this one (it has a name, I just don't remember it), is still in Peru, hanging out at some ancient ruins.

And what blog from Peru would be complete without alpacas?

So that was my day yesterday. Today, I had to go back to work (I know, it's not just a free vacation courtesy of the government). I went to the naval hospital for ID rounds in the morning, which was fairly quick--they have three patients, all of which are simple enough that they would have been outpatients back home. Then over to the cafeteria to have lunch with the officers at NMRCD (while making fun of the vast number of uniforms the Navy has... there's an Army vet and an Air Force microbiologist at the lab as well, so we got to gang up on the Navy officers), and then a quick lecture from LCDR (Lt. Commander) Maves, the ID physician whom I'm essentially working under for this rotation, and then back to the hotel to hit the gym and do some homework (which is still sitting in my backpack, waiting for me).