6-8-13: Change of Pace

Today was much better than yesterday. We actually got to rotate physicians today, so I was working with Dr. Patrick (no idea on his last name), the deputy commander of the hospital, in the internal medicine consult room. Meanwhile, Dr. Mann, our infectious disease pediatrician, worked with the doctor I had been working with. She said that he tried the same stuff with her as with me, the “this is how we see a patient…”, “this is how you do a physical exam…” stuff, but she put an end to it by repeatedly insisting that she had been a doctor for ten years, she knew that stuff, etc, etc. So because she was being aggressive, he finally started to treat her like an equal, and at the end he said, “I guess one of the American doctors knows something.”

                

Thanks, guy.

                

Meanwhile, I was over in internal medicine consults, where Dr. Patrick was going through patients at a much quicker (and more reasonable) pace, and for each, asking me about my differential diagnosis and how we would make the diagnosis in the States. It was so nice to be treated as somebody who actually knows something about medicine. I discovered in the course of conversation that they use the word “malaria” the way we use the word “flu”. It’s not so much a medical word to describe a particular diagnosis, but a general word to describe any illness. They call real malaria Paludisme (for Plasmodium), like we would call the real flu Influenza.

Yellow Fever and Malaria signs

Now that that has been explained to me, things make a lot more sense.

                

We finished the day with academics, which was to finish the malaria lectures (there was one we didn’t get to) and then onto TB. The DRC physicians explained their programs, program objectives, and their numbers, and I’m actually really impressed with how robust the program is. Kitona was apparently the pilot health zone for the new program, and comparing numbers to historical numbers, it’s looking like it’s making a difference.

                

Their goal is make TB “not a problem” by 2050. Guess we’ll have to wait and see.

TB treatment regiments (yes, I needed a translator for this, too). 

Tomorrow is Cultural Day, since there’s nothing going on at the hospital. Should be fun. 

Last Day of the TB Course

Today was the last day of the Denver TB Course (in case you couldn't tell from the title of the post). Most of the lectures today were about non-tuberculous Mycobacteria, or NTM. These are bacteria that are related to TB, but a little bit different, and so they cause a little bit different kind of disease. They're also usually more difficult to treat, sometimes requiring medication for years to a lifetime, sometimes requiring surgery. Fortunately, they are also a lot less likely to affect people who are otherwise healthy. Most people who get NTM infections have other diseases, such as HIV, cystic fibrosis, diabetes, cancer, or other diseases that require steroid medication. That isn't to say that otherwise healthy people can't get NTM infections, it's just more rare.

That being said, because TB is becoming so rare in the United States (and chronic diseases are becoming more common), most of the Mycobacteria in the US is actually NTM.

We also talked about multi-drug resistant TB (MDR) and extensively drug resistant TB (XDR), which are becoming increasingly common around the world (remember the report in the news a few years ago of the guy who flew all over the place with TB? He had MDR, and ended up at National Jewish). MDR and XDR are increasing around the world in large part because people don't completely treat their TB infections. It's a long course of a lot of medications--a typical TB infection in the lungs requires two months of taking four drugs, followed by four months of two drugs--and while the WHO calls for all of that to be directly observed therapy (DOT) to make sure that all of the doses are taken, resource-limited countries aren't all that great at always doing it. People who take the medicines for a short time and then stop, or take some medicines but stop others, increase their chances of ending up with a drug-resistant form of TB that is very difficult to treat.

In all, the TB course was pretty valuable and I feel like I learned a lot that will help me in the future. There was some stuff that isn't necessarily relevant for a preventive medicine physician (if I get a person with MDR-TB, I'm not going to be treating him or her; I'm going to be calling my friendly infectious disease physician and handing the case over), but it was still interesting. So you can rest assured that your tax dollars went to a good place (at least this once).

Not quite timely, but still appropriate:

TB Course, Days 2 and 3

I realized this morning that I forgot to write about my day at the TB course yesterday. Oops. So today's entry will serve for both days. First of all, here's a picture of National Jewish Hospital back when it opened as a TB sanitarium in 1899:

Yesterday was a mix of helpful and not helpful information, which mostly means things I will need to know as a preventive medicine physician and things I don't need to know. How to screen people for latent TB is something that I need to know, because that's something that preventive medicine physicians do. Here's the reason why:

 

What this says is that if you have 100 people who are exposed to TB, 70 will be fine and 30 will become infected, which is known as latent TB infection. Since TB is such a slow-growing bacteria, for 27 of those, the infection will always be latent and they will never have active TB. For the remaining 3, half will have disease within two years, and the other half will have disease later in life (okay, bad example, since you can't have half a person, but you get the idea). The point of treating people with latent TB is to reduce their risk of having active disease in their lifetime from roughly 10% to less than 1%.

And this is how you screen someone for latent TB. When you have a person at high risk, such as someone born outside of the US or someone who has been around someone with active TB, you do either a TB skin test, which is also known as a PPD; or a blood test (IGRA, or immunoglobulin release assay). If that comes back positive, you do a chest x-ray to look for active TB. If the chest x-ray is abnormal, you probably end up treating for active TB, but if it's normal, they're said to have latent TB. And again, the reason why we treat people with latent TB is to reduce their risk of progression from 10% in their lifetime to less than 1%.

That was a good deal of yesterday and a bit of today. Today we also did a workshop for TB outbreak investigations, which was interesting, because there's a change I'll be in charge of one of those someday. It was kinda a good feeling that I got during this workshop, because I felt like I had a better handle on the situation than most people in my group, which makes me think that if I have to do that someday, that maybe I won't mess it up too bad.

Here's a parting thought for tonight, from the CDC doctor who was sent to Colorado to close their sanitariums and ended up staying for the rest of his life:

Denver TB Course

As seems to be the trend for this year, I'm again away from DC, this time to Denver for the Denver TB Course at National Jewish Hospital. Here's a picture of the building the course is in:

This is the 49th year of the TB course at National Jewish, which established itself as a TB mecca of knowledge, so to speak, back in the days of sanitariums. What I didn't realize until the History of TB lecture today is that the practice of sanitariums started in Europe, in the Alps, around 1865. In the States, it started in the Adirondacks in 1884 with Trudeau (the great-great-grandfather of the comic strip artist, I believe), a physician in New York, who was diagnosed with TB. At the time, that was pretty much a death sentence, as they didn't yet have antibiotics to treat it. So he left his practice and went up the Adirondacks to relax, and his symptoms improved. They thought it was the elevation. Well, since the Adirondacks are pretty miserable for most of the year, and the Rockies are fairly nice, the practice of traveling to sanitariums moved from upstate New York to Colorado. More people traveled to Colorado for TB treatment than to strike it rich at the gold rush.

After our History of TB lecture, most of the lectures were introductory, covering topics such as transmission, immunology, diagnostics, and chest x-ray findings. Most of it was pretty dull, actually, although I did pick up a few pointers in the x-ray lecture. I'm hoping tomorrow will be more exciting. We'll be discussing some challenging cases that they've seen here at National Jewish, than latent TB infection (which is pretty much all preventive medicine physicians deal with, in terms of TB), and more about treatments and drugs. Should be a good time.