Pyoderma Gangrenosum

An informative post for those that feel the need to learn about skin conditions.

This is a quote from an awesome resource called, "UpToDate."

Pyoderma gangrenosum — Pyoderma gangrenosum occurs in up to 5 percent of patients with ulcerative colitis and 2 percent of those with Crohn's disease [5,6] . Despite its relatively infrequent occurrence, it often has more serious consequences than erythema nodosum such as persistence of the lesions and local discomfort even with appropriate therapy.

The lesions initially may appear as single or multiple erythematous papules or pustules that are often preceded by trauma to the skin (show picture 2). They occur most commonly on the legs, but can develop in any area of the body, including the abdominal wall adjacent to the stoma after colectomy as well as in other surgical scars or areas of trauma [7] . Subsequent necrosis of the dermis leads to the development of deep ulcerations that contain purulent material which is usually sterile on culture (show picture 3). Biopsy reveals nonspecific findings consistent with a sterile abscess (show histology 1).

Pyoderma gangrenosum lesions parallel IBD activity in only about 50 percent of cases [8] . Therapy directed at the underlying IBD usually results in healing in these instances, although treatment often needs to include a several week course of high dose prednisone (60 to 80 mg/day) or pulse methylprednisolone (1 g/day IV for three days) [9] . Other potential therapies include topical and intralesional steroids [7] , 6-mercaptopurine or azathioprine, topical cromoglycate, dapsone, clofazimine, granulocytapheresis, cyclosporine, and hyperbaric oxygen for those who are intolerant or resistant to high-dose systemic steroids [9-14] . In addition, infliximab was effective in case series and a small placebo-controlled trial [15-17] . Topical or systemic antibiotics should be added if bacterial superinfection is documented or suspected. (See "Neutrophilic dermatoses").

The (expected) unfairness of it all

Quick note: being on call has its ups and downs. On my last call I got to sleep for 5 hours, the call before that I didn't sleep at all. And finally, I am on call this weekend --> Labor Day weekend! Gah!

On my last post-call day, I had to present one of my patients to this super hard attending in the Intensive Care Unit. That is fine and all, I had time to prepare. So, being the good med student that I am, I researched everything and went over my findings with my R2. The R2 agreed with me and so I thought that I was golden. :)

I presented...

and...

was shot down.

By both my "normal" attending and the intensive care unit attending. The crappy thing was that when the ICU attending began explaining what the answer might be, the R2 totally acted like the plan was all my idea and she knew it was wrong all along.

You could say it made me feel kind of stupid.

Unfair? Probably. Unexpected? Not at all. Am I going to do anything about it? No.

At least I will learn from this experience.

Another quick note: My specialty "flavor of the month" now is Cardiology.

Remember when I said I wouldn't post much?

Yup. That would be right about now!

This rotation is kicking my behind. Being on call every 4th night is nothing to scoff at.

Here is what my schedule is while I am on call:
-Get to hospital at 8:00 am
-Go to required seminars and presentations
-Take care of current patients
-Begin admitting patients at about 1:00 pm
-Work up patients admitted to my intern (the resident who is my kind of "direct boss")
-If I am lucky, get about 2-3 hours of sleep at some point in the night
-If I am not lucky, like on Friday night, get absolutely no sleep
-Present patients to attending (my big boss) at about 7:00 or 8:00 am THE NEXT DAY
-Go home around 12:00-3:00 pm
-Sleep

I basically stay at the hospital the entire time. Because I am a medical student, my hours are not limited and I could actually end up staying until 5:00 pm or so the following day.

Needless to say, working a straight 30-40 hours is kicking my behind. And making it so I don't post that often.

I am currently at the Seattle VA hospital doing my rotation. This is interesting because in addition to the "normal" health problems, veterans have additional problems to deal with. And the population is mostly male.

Working at the VA has given me some laughs. A certain patient kept trying to call me "youngin" and would argue with me when I would tell him what the treatment was going to be. He talked down to me and basically made me feel like s***. So I laid down the law (so to speak) in two different ways. First, I said that I would answer to my name and that is it. And second, it so happens that as part of his work up he needed a prostate exam, so I was the one to give it. I normally don't enjoy doing these things, but since he really didn't want one and he was being a jerk to me, I enjoyed the fact that he was really uncomfortable with the fact that I was going to do the exam.

Payback is a b**** sometimes.

I am having to learn how to focus and think after being up for 20+ hours. It is definitely hard to do. The worst for me is driving home after being on call. It is a little like driving buzzed. Kind of scary, I know. But the awesome thing is that I have this SUPER DUPER COOL boyfriend who will come and pick me up if I need it. :)

A normal day (not on call) at the VA entails me getting to the hospital between 6:00-7:00 am and leaving between 3:00-5:00 pm. So that isn't too bad.

Well, that is a quick update on what is going on.

A lot of news

I know, I know.

I haven't been posting that much. I have been a bit busy and a lot of things have happened in regards to my "medical education."

In regards to finishing up my first 6-week rotation... Sigh. This is an interesting problem. According to the main doctor at the site, I did clinically and analytically well. Patients liked me and I genuinely cared for the patients. However, I wasn't told until my last feedback session (after I was done with the rotation) that the main doctor was having a personality conflict with me. There are a lot of details about this that I don't feel like posting because it is a sore subject with me. If you would like to know, please go ahead and email me. Just know that it will be somewhat of a "rant" email which is why I am not posting that "rant" on here.

Your time is worth more than that (unless my neighbor tries some funny business with another tree, then your time is worth a rant).

Moving on...

I started the second half of my Internal Medicine rotation yesterday. Holy gebeezus! My first day (that would be Monday the 18th) I was on call with my team. So, I got there at 7:30 am YESTERDAY morning and didn't leave until 3:00 pm TODAY. I got a total of about 2.5 hours of sleep while I was there. It was pretty cool because I got to do a lot of things already. I was first-assist on a paracentesis. I helped work up a patient with a GI bleed. And now that I am at a big teaching hospital, I got to do LOTS of rounds and didactic sessions.

I like it there, it is pretty busy and I actually get to work with residents and fellows so I can see how my education will progress.

Oh, and did I mention that I am on call every 4th night? So, my next call day is Friday. I will get there at about 8:00 am and then leave on Saturday between 12:00 and 3:00 pm. Life will suck for a bit. :)

This year will suck...

...

Not because of anything really negative, but I think that I will end up liking ALMOST all of my rotations. I liked just about everything I did in Internal Medicine. Since Internal Medicine is kind of a compilation of a ton of fields in medicine, that makes applying for residency that much more confusing.

Sigh.

I was supposed to only like one field and get into that one field.

Another dilemma...

Seattle? No Seattle? Yes, it is a conundrum. On one hand, I want to get into a residency in Seattle for obvious reasons. On the other hand, I want to go where the good programs are (in whatever I go into). What if that isn't Seattle?

Mike has said he will go where ever; but lets be honest, Seattle would be so much easier.

On another note... I got to remove 3 moles from a guy's back today because they bothered his wife. Amazing. I didn't know that "wives" have that much control.

Another day of learning

Today was chock full of new knowledge. Not the medical type, but the useful type that will help me be a better doctor type.

I did another one of those "shadow a specialist" things today. I am not going to tell you what specialty it was; mostly because there really aren't that many in this area so it would be too easy to pinpoint who I am talking about.

Hmmm, how is that for a build-up for a post that has a bunch of not nice things to say?

I am actually pretty conflicted about the doctor that I saw today. I know that I don't want to do his specialty. I am learning that I really need some kind of specialty that allows me to do in-patient care. I really like that aspect of medicine.

On one hand, the patients seemed to like the doctor. Two of the patients actually felt comfortable enough around him and I to start crying. (Yeah, some people would find that odd but think about that the next time you visit your doctor. Would you feel comfortable enough to cry?) Patients also told me that they really liked him. Those two points really impressed me.

On the other hand, get him into his office, and you see a different side. He complained about DOs, bragged about his MCAT score (that was a while ago), told me (and reiterated) that he was "competent" at what he did, and is a drug-rep doctor. He also gave me some "advice" that he learned from a family doctor (a doctor that even he said was bad), "Follow the 3 A's: availability, affability, and ability; in that order."

Oi.

He just confirmed the "thing" that I didn't want to be! I don't want to be "affable" but stupid.

I also learned that this area really needs doctors. I am surprised. I would think that being this close to the state capital would mean something, but apparently that is wrong. It really makes me think about why I took this path. I have always wanted to help where it was needed, right? But, when I left Shores, I swore off anything that reminded me of a small town. Could I deal with a place like this again (not Shores, never Shores)? I know that Mike wouldn't mind.

But then again... I like being in Seattle. I like going somewhere at 11:00pm knowing that it will be open that late.

Argh!

All of these damn decisions!

Internal Medicine

I finished my 5th week of my 12 week rotation in Internal Medicine this week. After the 6th week I will go back to the big city to be at the VA hospital.

I really liked my two weeks with the "really crazy busy doctor." I don't want to be as busy as he is, but it is because of him that I would really consider Internal Medicine as a field option for me. He had a good combination of hospitalist work and clinic work. While I was there I got to see a wide variety of things. Some patients had very complicated cases while others were just fine.

If I had only done this part of the rotation at the first site, I would not have added Internal Med to my "possibles" list.

Isn't that amazing!?

I could have possibly written something of "for forever" if I hadn't done this two week stint in this location. I wonder what that means for my other rotations.

THE Experience

This is going to be somewhat of a long post. Just thought you ought to know.

I know nothing.

My classmates and I have been told numerous times about this certain experience. I have read about it in different books as well. However, no matter how many times you are told about this type of experience, you can never (EVER!) be prepared for it. You just recognize it while it is happening and realize that all you can do is learn from it.

I felt utterly, completely, and universally inadequate today. I mean jaw-dropped-on-floor, want to cry and run home inadequate.

I will give you the general version of this experience followed with a specific description of what I wen through if you want to know the medical details. I will deviate from my normal way of writing and not create links for every medical term, it would take too long. If you really want to know, Wikipedia is there to help.

General Description:
I knew that at some point, all of my book-learned knowledge would be useless. It would go into hiding behind some lead-lined wall in my head right when I needed it. I was told that I would be put into some emergency situation and two things would happen: the first was that I wouldn't realize it was an emergency situation and the second was that I wouldn't know how to react (thanks to that lead-lined wall). This is what happened today. I walked into a patient's room with a doctor, the doctor realized that the patient was not doing well at all (READ: If we had walked in about 10 minutes later, we would have had a scene from ER running at the hospital). To my credit, I would have realized the same thing, only about 30 seconds later. The doctor began firing off orders in a completely calm and orderly fashion, while I stood on the sidelines trying to be useful by not getting in anyones way.

What a way to learn.

Specific Description:
At about 7:30 this morning, I was pre-rounding on a patient. This patient was morbidly obese (weighed about 170 kg - kilos people, not pounds) and had a history of: aortic stenosis, COPD, CHF, diabetes, and electrolyte abnormalities. Basically, she was not a "simple" patient by any means. I spoke with this patient for about 45 minutes, and she was mostly fine (as fine as can be expected) at that point. She was able to hold a conversation with me and coherently answer all of my questions. In fact, she had even been mad at me for waking her up and asking her a bunch of "stupid" questions. To move the story along, I did the physical exam and got her history. Out of all of the things that were wrong with her, there was one that didn't fit: her respiratory rate was somewhere around 30 per minute. Most physicians really wouldn't like this number. I understood it to be high, but I didn't realize that it was high enough to set off alarm bells. When I was presenting this case to an attending it was about 1.5 hours after I had interviewed her. After I mentioned the little tidbit about the respiratory rate, I was peppered with more questions and we decided to see the patient.

When we walked into the room, the patient looked sleepy. "No big deal," I thought, "She was like this earlier." Oi. The no-big-deal part didn't last that long. After trying to wake her up by saying hello, and her not really responding, the attending determined that she was crashing. (Enter the part where I hopefully would have realized that she was crashing about 30 seconds later if I had found her on my own.) After that, there was a flurry of action. The attending set a trillion things into action: and ABG was ordered, stat xray, stat EKG, 40mg of lasix, 2mcg of morphine, 125 (I forgot the units) of methylprednisolone, respiratory treatment, and stat labs.

And what was my job?

Attending: Stay here and watch what they do.

Me: Okay.

I did my job really, really well.

I had this horrible sense of helplessness and inadequacy. It is almost like watching someone die that you know and realizing that you almost know how to save them, but you can't pull that information to the front of your brain.

If I had discovered her by myself, the situation would have been different. I would have realized a little bit later something was wrong, then I would have either yelled for help for went to get the attending, and then the same scene would have played out.

Now that I have had a chance to think about all of this stuff, I realize that I am not completely useless. I understood all of the life-threatening things that could have been causing her shortness of breath. I just didn't know what to do acutely for them.

Medicine is a scary thing people! The nurse for that patient had just seen her 30 MINUTES before all of this had happened and she had been just fine. That is insane! 30 freaking minutes went by and this patient's body went from 'dealing with the problem' to 'f*** it, I don't care.' This was a shocking experience for me. I seriously called Mike after it was all done almost crying. I was just so moved by the whole experience.

I must try to get as much experience in anything that I can. I just feel so inadequate.

And to make my day even more interesting, I saw a sex offender today as a patient. I was instructed to leave the exam room door barely open, just in case.

Wow, talk about an interesting day.

Too close to see the growth

I am pretty sure that I have learned at least SOMETHING in the past 5 weeks or so. I am sure that it is measurable in some manner.

But I couldn't be the one to judge that.

This experience, I am sure, is somewhat like watching my puppy, Tesla, grow. At first, I could tell that she was growing even though I was around her almost all of the time. But now, the reason I can tell that she is growing is because I am gone the whole week and I only see her on the weekends.

The point...

I feel like I haven't grown or learned much in the past 5 weeks. What I have noticed are things that I don't feel are important. For example, I definitely feel more confident walking into a patient's room and FEELING like I am supposed to be there.

To me, important things deal with knowledge. I wish that I could remember something from just hearing it once and be able to apply it to situations as needed. I would like more confidence in my abilities (this last statement is kind of funny if you think about the fact that I have been talking about having learned nothing yet).

Well, this post is just kind of "blah." I really like the doctor that I am working with right now and I don't want to go back to the other one. Not that the other one is bad, but I like this pace better.

Did I choose you? Or did you choose me?

While being out here, I have worked with a total of 6 different doctors. It is great to be able to see the different ways that each practices medicine.

What I have come to notice is that eventually, patients and doctors match in personality and "style." For example, the doctor that I followed today has a reputation for getting extremely agitated if she gets behind even a few minutes. Also, even though she has 3 patient rooms, she only wants 2 filled at once because 3 makes her edgy. Interestingly, most of her patients are quick and to the point about why they are there. They get right down to talking about their symptoms, how they are feeling, and what they are worried about. All of this happens without the doctor seeming like she is pushy or trying to get her patients out of the door.

Another one of the doctors will listen to almost everything you have to talk about, even if it isn't the reason that you came in to see him in the first place. As you may have guessed, a lot of his patients talk a lot and he is usually running about 30-60 minutes behind schedule. That may sound frustrating to some of you (maybe you would work better with the other female doctor I mentioned...) but his patients know that when he finally gets to them, he will also give them all the time they need.

It goes on and on. So I guess that means that if someone recommends a doctor to you, you should ask that person more questions about how the practice goes. For example, if you really wanted a doctor that spent as much time with you as necessary and didn't mind being late, the person recommending the doctor to you would need to give you more details about how much time the doctor spends in the room with the patient.

My point is that how did the patients and doctor end up together? These types of things aren't really advertised anywhere but most of the patients seem to work well with the doctor's style.

At this point, I think I am leaning more towards the female doctor in this post. I wouldn't be exactly like her, I don't think I would flip out about 3 patient rooms being full. But I would like to keep things on schedule as much as possible.

My Weekend On-Call

This weekend had its ups and downs.

I got to help do a thoracentesis as I mentioned earlier. I saw how admission to a hospital works. However I really don't think that I learned much. My attending was trying to expose me to as many things as possible so that I would be prepared when I went to the "big hospital" up here. What ended up happening was that I was overwhelmed by all of the things, I didn't get a good grasp of any single thing. I will only know later if this experience has helped me.

Another bad thing was that my attending and I got on each other's nerves by the end of the weekend. This is partially due to my personality and partially due to his. He had mentioned earlier that usually by the end of his weekends on-call, he gets annoyed at people constantly needing something from him. Our housing situation was setup so that I stayed with him in a house that the hospital owned. Of course, we had our own bedrooms but it was weird staying with him. It also meant that we spent more time together (probably a bit too much). By the end of the weekend, I was feeling pretty crappy because I felt like I wasn't doing well with anything.

So, together, it didn't make for a good combination. Which sucks when I am the medical student and he is giving me my grade.

I guess my overall feeling is, "eh." I could have only done the call for one day and had gotten the same thing out of it. Kind of sad because I would have enjoyed spending the time with Mike instead.

It was the non-hospital experiences this weekend that I really liked. My attending thinks that I will become a pediatric intensivist. Interestingly, this is a field that I have considered and really like. But, who knows. I like lots of things. Cardiology is also pretty interesting to me. What I have figured out is that I am going to specialize in "something."

Editor's note: As I read back over this post, I realize that it sounds very negative. I am not changing it because I want to be able to read back over it at a much later time and see if I still think the same thing. So, dear readers, please don't think that nothing good came of this and it was a waste of time. As I get into a better mood, or as I enter the "big hospital," I may realize all of the good things that I had while I was on-call with him.

Non-medical school related rant (just a warning)

We have this neighbor.

Oh, and this will be a long post.

Sigh.

She is somewhat nosy and very picky about having things done her way.

Which is fine and all, as long as she is only picky about her stuff.

We have this tree.

Wait, back up. SHE has this tree. Most of this tree has berries that fall on our side. It is a Mountain Ash tree.

It produces fruit in spring and then the fruit fall off. Into our yard. We don't like these berries for a few reasons: the dogs eat them, the dogs track the berries into our house, and we track the berries into our house. Granted, the berries aren't poisonous to our dogs, but I still don't want them eating things that they shouldn't.

We have spoken with out neighbor a few times about this tree. She just keeps telling us, "Well, the berries aren't poisonous. You should just keep outside shoes and inside shoes. "

We aren't sure how the shoe recommendation would work for our dogs.

She was nice a few months ago and somewhat trimmed the branches (with a professional service).

Oh yeah. ALL OF THE BRANCHES ARE ON OUR SIDE OF THE FENCE. So she has the trunk on her side, and the berries on our side.

Mike spoke with her earlier this week and asked if we could remove some of the branches that had berries on it. She agreed to let him do that. But there was a miscommunication. She assumed that we only meant the tiny branches that directly held the berries. Mike meant the big branches that held branches and branches and branches of berries.

So we cut one down this evening. And while our neighbor was staring out of her window down into our yard, she realized that something was happening that she didn't like.

To make a long and annoying conversation shorter, the result was this:
-Neighbor doesn't want us taking down any branches, she acknowledged on her own that all of the branches are on our side, and she thinks that this is a malicious attack on her (side note on that one... She had her tree pruning service out earlier in July and when they trimmed some other trees of hers and some branches fell on our property. No biggie. What happened was that when the pruning people came onto our property to clean up the branches without asking permission, they removed one of Mike's broccoli plants. One plant isn't a big deal. But was kind of crappy that they didn't even try and pay attention to his vegetable garden when cleaning up. Our neighbor was told about this, because we wanted to say that if they prune branches WE would clean it up. She made the pruning service buy Mike new seeds. Not what we were going after.) So when she went inside her house, she muttered, "One broccoli plant, one branch. I see."
-Neighbor complained about one of our trees that was completely on our property and said that it blocked light on her property so that she couldn't grow what she wanted there. She then offered to remove the tree with the berries if we removed that tree. We agreed.

She didn't like that response. She put herself between a rock and a hard place because she made an offer that she needs to follow through with. We have already started removing big branches from our tree.

The only thing that we could have done differently was pay a professional pruning service to remove the branches that have berries on our yard. But, as she pointed out, that would make it so she basically has no tree there.

We have spoken with her for months about this. We have tried to be very nice about it. But tonight it came down to saying that it is our property and we don't want them there. Mike and I don't want to piss off our neighbors, but you can only do so much.

Argh!

Sorry for the super long rant about nothing related to medicine. I just cannot believe how amazing this is. It really makes me mad that she thinks Mike would do this just to "get back" at her about a stupid broccoli plant. Are you kidding?

Yay!

I got to help do a thoracentesis! My attending did the first "poke" for guidance, then I did the second poke for draining a bunch of fluid from the guy's chest.

Nice.

This weekend

I am on call this weekend. So, no posts. Hopefully I will write one on Sunday about all of my adventures.

:)