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.

Last day at work

Today was my last day in the Allergy and Immunology clinic. It was a typical day at work, albeit a bit short (no patients scheduled for the afternoon--yay!). I evaluated a couple of patients, wrote a couple of notes, chatted with COL Yang and LTC Marks for a bit, and then headed to noon conference before heading out for the day. I decided to hit the gym for what will probably be my last time swimming in an outdoor pool in November for awhile.

Anyway, here's the "office" I've been using for the past month. It's not as much an office as a storage space for extra stuff that just happens to have a computer.


So, tomorrow I have outprocessing--ugh. Walking through the hospital getting signatures from various departments (security, computer IT, etc), asking for permission to go home when I don't want it, is never my idea of a good time.

Transient hypogammaglobulinemia of infancy

No, the title of the post wasn't me slamming my hands against my keyboard. That was the disease (well, not really a disease...) one of my patients had today.

The reason why I say it isn't really a disease is that transient hypogammaglobulinemia of infancy is a normal variant of the immune system of children. When born, babies have their mother's antibodies. As the months go on, those antibodies begin to fade, and the baby's own immune system is supposed to take over. Sometimes there's a bit of a lag between those two things happening, leaving the kid with low (hypo) antibodies (gammaglobulins). So, there are low levels of antibodies in the blood (-emia), you get hypogammaglobulinemia.

The kid today was a twin born at 34 weeks (remember from my OB posts, a full-term pregnancy is anything between 37-42 weeks). Since he didn't have as much time being fed from the placenta as he should have, he didn't have as much of his mother's antibodies as he could have used, which meant his levels got lower than they should have. At Ft. Knox (where he was born), he had several ear infections starting at 3 months old, which prompted a referral to the immunologist. He did blood tests and saw that there were low levels of antibodies, so he diagnosed transient hypogammaglobulinemia of infancy. Technically, the "transient" part can't be diagnosed until it goes away, which is why he's following up now--to get blood drawn again to check the levels. Since he hasn't had many infections in the last six or so months, we're pretty sure even before getting his blood that he has appropriate levels of antibodies for his age.

On a completely different note, I've mentioned a few times the hills of Tripler, so I included the elevation map (green line on the graph) of my usual run from my GPS watch. That loop takes me completely around base--like Walter Reed and unlike Madigan, Tripler is a stand-alone base, not part of a larger one. So it's a pretty small world I'm living in this month (obviously, as there's not even a place to buy food on base).

Medical board

My first (and only) patient of the day was already in when I arrived at clinic from morning report, getting his skin tests. He was a bit unusual in that he wasn't a new patient; he had been seen by COL Yang about a year and a half ago, before he was deployed to Iraq. At that point, he was being evaluated for his deployability, due to his history of allergies diagnosed and treated by a civilian allergist since he was a teenager. Needless to say, COL Yang determined him deployable (ie, his allergies wouldn't be enough of a problem to prevent him from doing his job in Iraq).

Well, unfortunately for the patient, he got in a motorcycle accident while he was on R&R nine months into his deployment, landing him in the hospital and rehab back in Hawaii. He messed up his shoulder during the accident, and there wasn't much a motor transport operator (88M for those of you familiar with Army MOS) could do, so he's been spending most of the last year on a medical profile. When it became obvious that he wouldn't be able to do his job again, he was referred to the medical board for a medical discharge. One thing that happens on medical board is they go through your medical record (obviously) and go over everything they've seen a specialist for. So, he had to go back to COL Yang to be evaluated for his allergies again. Guess what? We discovered he still has allergies (surprise, surprise). So we refilled his prescriptions, recommended he get hypoallergenic mattress covers and pillows, and determined that while he does have allergies, it wouldn't prevent him from retention (staying in the Army), which gave him a 10% disability with the VA (from what I figure, that means they have a condition that requires specialty care, but doesn't really cause disability). Conditions are summative; if someone has five conditions that each cause 10% disability, he is considered to be 50% disabled. In the case of this patient, his shoulder/back injury from the motorcycle gives him more than enough to get his medical discharge and to get full medical care from military facilities for life.

So, my one case today was yet another example of government red tape--a man who quite obviously can't do his job requiring him to lift 200+ pounds of equipment being evaluated for the dust mite allergy that causes him to sneeze.

Long commute to see the doctor

Yes, I know, it's been quite a few days since my last post. Unfortunately, not much has happened.

On Thursday (I think it was it Thursday), we had a patient who had quite the commute to see the allergist--all the way from Okinawa, Japan. He moved to Okinawa about two years ago, and about a year ago, began to notice a really itchy rash that instead of going away, got larger. He tried allergy medicine, tried washing his uniform every day, and tried just about everything else that people recommend for exzema. It got so bad that he was going into sick call almost every day, and had to be transferred from his job outdoors to an office job. Finall, his PA got him an appointment with the one dermatologist at Okinawa (after a few months waiting, of course). They tried him on over 20 different medicines; some made it slightly better, some did nothing. Finally, they got him an appointment with the closest allergist, which just happened to be COL Yang here at Tripler.

So we saw him and said, yep, that's exzema. So we got him some different medicines, one that he had tried and two that he had not, and then sent him back to Japan and told him to continue following up with the dermatologist. Hopefully this will take care of it. Since he can't really do his job with this exzema, the next step is to move him away from Okinawa, probably back to El Paso, TX.

Anyway, that was the most exciting patient all week (week-ish, I guess). Yesterday I walked down to the NEX at Pearl Harbor (about 4.5 miles) and did some shopping (not much, since I had to walk back). Today was another diving day. We went out of Waianae Bay, which is on the west side of the island (Tripler is close to the south). It was beautiful weather for diving while we were diving, then it instantly started raining as soon as we got the boat back to dock. Here's a picture from the boat.

I didn't get back to base until about two, and then I was tired from diving, so I didn't do much the rest of the afternoon. Then around six (when it started raining again), a couple of other students and I grabbed a cab and went down the NEX for dinner and do some grocery shopping.

Tomorrow, it's back to work, for my last (and second) full week of work at Tripler.

Back to work...kinda

After four days of vacation, it was time for me to go back to work... and I use that in the loosest sense of the word. After morning report, Dawn (the University of Hawaii med student) and I headed down to the Allergy and Immunology clinic, logged into our computers, and found that there were no patients scheduled for the day. COL Yang was working vaccine clinic in the morning and had an administration day in the afternoon, so nothing for the med students to do. He gave us the morning to study and told us to report back at 1300 for lectures on allergic rhinitis and urticaria (hives). So I did some OSU on-line lectures in the morning (as this is a required rotation), headed back for a noon conference lecture on anorexia, and then back down to clinic for two hours of lecture. In other words, it was a long day of lectures.

But here's a picture from the allergy and immunology clinic window.

Vaccine reactions and long runs

So this post is a couple of days overdue, but such is life. I don't know if I mentioned this, but when I was working with COL Yang in vaccine clinic on Tuesday, I got my third Japanese Encephalitis shot (better for the taxpayers to pay than me). Well, as can happen with vaccines, especially the third shot in a multi-shot series, I got a local hypersensitivity reaction. On Wednesday, I noticed a rather large wheal (elevated swelling on the skin; think mosquito bite):

And no making fun of me for my methods of taking pictures of my arm using a phone and a mirror. Anyway. by Thursday, it changed from a wheal to a large urticaria (think one large hive).

It was incredibly itchy, but fortunately for me, I'm working in an allergy and immunology clinic, where there is plenty of Benedryl. Problem solved. By now (Sunday), the skin is still a little tender, but there's no more swelling or itchiness.

Anyway, enough with my medical issues. I wanted to go on a long(ish) run today (6-8 miles), so I looked up Oahu running trails and selected one around Diamondhead Park. Unfortunately, I not only got lost driving to the park, but also got lost while running, so my longish run turned into a bonafide long run, around 10 miles. Not so much fun with hills and tropical sun. Fortunately, I saturated myself in sunscreen first, so I'm not too burnt.

After that, I hung out at Ala Moana beach, which has really calm water, good for swimming (I did swim a bit, but I forgot my goggles, and salt water and contacts don't mix). If I get any more afternoons off, I might have to take the bus there for more swimming.

Pictures

As promised, here are my first pictures from Hawaii. Dan (the HPSP student from West Virginia) and I went down to Waikiki on Sunday for dinner. Here's a picture from the beach:


And here's the Mountainside of Tripler (the two main buildings--which are connected--are called Oceanside and Mountainside). I took this on my walk up to the Tripler Lodge after work on Monday.
And more of the same from further up the hill. By the way, these hills do NOT make it fun to go running.

More pictures to come later (as I take them, of course).

It was more of the same at work today. COL Yang was doing vaccine clinic again this morning and had Dawn (the University of Hawaii fourth year med student) working with him, which left Tracie (the PA student) and I with nothing to do. After lunch and noon conference, we had one new patient, a woman with some sort of environmental irritant in the building she works in that has been preventing her from going to work. Even though the history wasn't consistent with allergies, we did skin tests on her anyway, which were, not surprisingly, negative. Chemical irritants (ie, perfume, cleansers) aren't allergies, and can't be treated with medicine like allergies. So we scheduled a follow-up (for what, I'm not sure) and sent her on her way.

After work, I decided I needed food, which is not to be found at the Tripler base, so after one of my usual laps on base, I ran to Ft. Shafter (about two and a half miles away) to visit their very small PX/Commissary before making the trek up and down the hills back.

Not sure what's on the schedule for tomorrow, but I'm guessing it won't be too different from any other day.

Free vaccines in the Allergy and Immunology clinic

Okay, technically, there are always free vaccines (at least to military personnel, dependents, and contractors) on military bases, but I saw it first-hand today while working in vaccine clinic. It was pretty fun, actually--people were lined up with their papers saying which vaccines they needed, COL Yang would chat with them for a couple of seconds, sign their papers, and send them to the Specialist to get their shots. I realized that since I'm on active duty this month, I also qualify for free shots, so I grabbed my own sheet of paper, gave it to COL Yang, and got my third Japanese Encephalitis shot, saving myself about $100, which is what it would have cost to get it at the OSU Health Center.

After a fun and exciting day in vaccine clinic, I got off work at 1500, went on a run (running up and down a Hawaiian mountain may sound fun, but it's actually hard work) and then grabbed a taxi to go into Honolulu for dinner. There is absolutely no place on base to get food--at all. There's not even a PX or commissary.

I did get a new sync cable for my phone, but it still isn't working, so there's something wrong with either the phone or the computer. Hopefully it's something I can fix.

Aloha from Tripler!

Yesterday, after a very long day of flying (hour and a half to Atlanta, nine and half to Honolulu), I arrived in Hawaii, got my two very large bags from baggage claim, climbed into a taxi, and checked in at the Tripler Lodge. During the flight, I met another HPSP student, Dan, so it was nice knowing one person on the island at least. After unpacking all the stuff I need for the month (and calling Adrienne and bragging about how sunny and warm it was), I discovered that there is no food to be found on base on Sunday nights. So Dan and I hopped on a bus toward Waikiki, wandered around the touristy areas for a bit, and had dinner at a nice Thai restaurant before heading down to the beach for a bit (can't arrive to Hawaii and not go to the beach on the first day, after all). I took pictures, but they're on my phone, and I discovered this morning that I grabbed the wrong sync cable to connect my phone to my computer, so until I get another one, no pictures from the phone.

This morning started the same as every other Army rotation: wake up, eat breakfast, wander around the hospital for a couple of hours in-processing. Then I met the chief resident of Internal Medicine and got a tour of the medicine department before he took me down to the allergy and immunology clinic. Turns out, the attending who was coordinating my rotation is now deployed, and forgot to share with the other attendings that I would be coming. Oops. So we laughed about that for a few minutes, then I went and started seeing patients.

Other than seeing a couple of patients a day in clinic, I have morning report every morning at 0730 and noon conference at 1215. There are no calls (yay!) and no weekends (yay!), so I have the evenings and weekends to myself. So far, that means I did (well, I'm still doing, technically) some allergy reading tonight, and called the dive master Daniel Christian recommended. My first dive in Hawaii is at 9 on Saturday morning, and I'm really excited about it.