Ain't Nobody Got Time For That

I never liked Chinese New Year. It is the time of the year that reminds you that there are people in your life that you need to get rid of.

Toxic people. People who tries to make you feel small because they are insecure in themselves; people who curse you because they are jealous of you and people who are so fucking selfish they would take advantage of the elderly or disabled.

Oh yes there ARE people like that. Not just anyone, but relatives.

Well the truth is, I don't care one bit. Because even if allegedly you people have some vague blood ties with me in some way or other just because we are related, I AM NOTHING LIKE ALL OF YOU. I would give a gazillion bucks to bet that my set of DNAs are nothing like yours too. As far as I am concerned, you are NOT family to me.

But I do care if you hurt MY FAMILY.

So back off. Go hide behind your pompous shells and mind your own goddamn business. Oh, and do us all a favor, don't ever come over to 'visit'. Because we all know, that those visit are just to borrow more money or to steal someone's fridge magnet or your elderly mother's coffee powder. For God's sake, how low can you people get to?!!

Well then, hope you get rich one day just by saving up on paying your part of grandma's monthly medical bills of approximately....... 30 dollars.

IDIOTS. 

Valentine's Day

It's basically just like any other day. Albeit over-commercialized.

At least the Boy's here with me. And I'm not working that dreaded 15-hour weekend shift.
That's good enough for me.

I thank God today for having him (and all his leftover reports from work) here with me on our very first Valentine's Day together as a couple.
I thank God he knows me well enough to have the sense not to spend unnecessary money on flowers that will wither or chocolates that will exacerbate the ache in my sensitive gum near my left premolar.

Instead he brought me a whole box of (healthy and not-so-healthy) snacks that I can have in bed while reading my ALS course preparation handbook. (Think pine nuts and pork crackling) Also, Indian takeaway for dinner. Pea pulao and garlic naan's the best.

I pray for the many more Valentine's Day to come. That the Boy will be here by my side, regardless of whether we celebrate it or not. I  don't need any expensive gifts, fancy fine-dining or fireworks. Just us, together. Spending quality time, sharing workplace gossips.

To me, that's the best kind of Valentine's Day.

Burkholderia Pseudomallei

Doesn't that sound lovely?

I have been learning a lot about infectious disease these days. (Who says orthopedics is only about the bones?) One would think that in a little hospital like this, you do not come across many types of bugs. Mainly just the Staph Aureus, at times some C.Diffs, and occasionally some gram negs (proteus mirabilis). 

How wrong were we. 

For on this faithful week, we were visited by not one, but two rare infections amongst our inpatients. I am not going into much details as it will be a boring read (I don't have many viewers to start with and this would definitely send the last of them fleeing - microbiology seems to be everyone's least favourite subject).

Hence, quick succinct case summaries as below, with plans as per ID consultant from Hobart:

Case 1

65yo F, presented with septic L knee. 

Joint fluid culture grew Burkholderia Pseudomallei.

B/G - Recent visit to Darwin during wet season. Had pneumonia 4 weeks prior to this admission - now resolved. No past medical history. 

Dx - Clinical picture consistent with melioidosis.

Mx - Extensive investigations warranted as occult sources of melioid might be present and can be asymptomatic (ECHO, CT, bloods etc). IV meropenem cover for at least 4 weeks, and then at least 6 months of oral antibiotics as prolonged eradication therapy.  Weekly bloods + inflammatory markers. Repeat investigations down the line as well.    

Sounds like a big deal? IT IS A BIG DEAL. Not a bug you ever want to get, as it has a high recurrence rate, as well as being associated with high mortality and morbidity. Technically, it behaves kinda like TB. Both being tropical diseases, endemic in Northern Territory of Australia, and South East Asia. Usually spread via contact with contaminated soil or water, at times even via inhaling dust particles. Increased susceptibility among the immuno-compromised, diabetes or cystic fibrosis patients. 

Main cause for melioidosis. Melioidosis is an infection caused by Burkholderia. Signs and symptoms may include pain in chest, bones, or joints; cough; skin infections, lung nodules and pneumonia. Might even cause liver abscess - typically with a "honeycomb" characteristic. Lung nodules and liver abscesses might at times be asymptomatic, hence the need to perform extensive investigations. The strange thing is, melioidosis is said to be able to affect any organs except for the heart valves (endocarditis). (*We are not sure how far this is true, so we did an ECHO just in case.)

Case 2

48yo F, presented with infected R index finger.  

Wound washout m/c/s grew Roseomonas Gilardii. 

B/G - Previous similar infection in thumb. Both infections requiring repeated surgical washouts and debridement. Both infections arise from simple cuts from household work. Works at a milk processing factory in the packaging department. 

Dx - Infected R index finger

Mx - x2 surgical washouts and debridement. For IV Tazocin + oral Ciprofloxacin until wound-healing is satisfactory. Then stepdown therapy with oral Ciprofloxacin + oral Augmentin DF for another 2 weeks then cease. For investigations of why she suffered recurrent similar infections (likely linked to her workplace). Occupational health physician to review with regards to workplace safety and prevention/precautions to be taken.

As compared to Case 1, this is a less menancing bug. However, it is very rarely known to cause human infections, and we were unsure how did the patient actually pick it up. Transmission is via contact with contaminated soil or reservoir water. The most likely explanation was that the source of infection was from her workplace, possibly from the pumped creek water they use for general cleaning purposes. 

Roseomonas infections tend to occur in the immunocompromised or debilitated host. Most patients recover completely from their infections. Bacteremia is the most common clinical presentation reported in the literature. The patients generally present with fever. Other rare presentations reported in the literature have been peritonitis, septic arthritis, ventriculitis, left ventricular assist device (LVAD) infection, vertebral osteomyelitis and keratitis.

Once again, kudos if you survived my boring blog post up to this point. You may call me a nerd, but I actually found these cases pretty interesting, so I thought imma share with you this time. Even the ID consultant was like:" these are not infections that you will normally see. You might not even get to see another case of Burkolderia infection ever again, especially if you are working in this part of the country (the very much non-tropical Tasmania)!" 

Once again, behold the beauty of a Burholderia colony on blood agar. And culturing these is apparently a biohazard to the lab and special isolation is needed! (sounds cool! Made me think of  my fav zombie movies i.e. Resident Evil) 

*all patients are fully de-identified and no patient details contained in these case summaries* 

Typical Day of an Orthopaedic Intern

I find working strangely calming. Being constantly on-the-go, with missions to complete and new issues popping up every now and then to add to your list is actually kinda exhilarating. And I just love how time flies without you even noticing it. These days it seems like time is no longer defined by the numbers, but rather, the jobs left to be done before 5pm.

If you are ever curious about how a typical day goes for an orthopaedic intern, let me enlighten you with a timeline (say for today). Hold your breath, here goes.

6.30am - Arrive at the surgical ward. Update patients' list. Add on new admissions, check progress of all patients overnight, chase bloods and imaging results. Do your own pre-rounds (before the reg's pre-rounds, and wayyy before the actual ward rounds) if time permits.

7.00am - Registrar arrives at ward. Print patients' list to hand out to the team. Paper round with registrar to update him/her/them about all patients. Registrar does his pre-rounds. Carry out new jobs (eg: order repeat bloods/XRays for post-op patients)

7.15-7.30am - The rest of the team (consultants, allied health members and occasionally nurses) arrives. Official paper round of the morning - team will discuss patients' issues, and coming up with plans. Intern to note down plans and carry most of them out later in the day.

7.30-7.45am - Commence ward rounds. Interns leading the way and showing the team to the rooms and patients. Also looking for patients' obs chart. More jobs might be added to list as we go.

8.00-9.00am (depending on patient load and complexity) - End of ward rounds. Consultants and registrars off for coffee/clinic/operation theatre. Interns return to doctor's office to write progress notes in retrospect for the ward rounds in each patient's folder. Liaise with nurse unit manger about plans for each patient under our care. Also liaise with nurses looking after each patient if there are any specific jobs to be done (catheter to come out/new medication charted or ceased/obtain urine sample/stitches or staples to come out etc).

9.00am to 12.30pm - Completing jobs and chasing up results. For today, we had to chase an ID consult, chase an ECHO, chase x2 blood cultures, chase x2 urine mcs, discharge x3 patients, and also prepare discharge scripts and paperwork for another x2 patients for discharge to nursing home tomorrow. Also x1 palliative care referral and x1 opthalmology referral. While we are going about completing jobs, nurses might approach us about new issues about patients under their care, and we will need to review or manage accordingly. For today, we had a post-op young guy who failed to void and requiring a catheter. There was also a cannula to be resited. Multiple medications to be recharted. A lady with low blood pressure and query to withold frusemide for today. Meeting family member of a paediatric patient to discuss ongoing management and compliance issue. Providing

12.30-1.30pm - JMO education sessions every Tuesday for an hour. Today we learnt about how to assess journals from the hospital library.

1.30pm to 5.00pm - Continuing where we left off, completing the rest of the jobs leftover from the morning. I attended the palliative care consult for one of our patients, and discussed the plan with the consultant. Received phone call liaison by the ID team at the Royal Hobart Hospital (gosh I miss that place!) and confirmation of antimicrobial therapy for patient with septic knee. Then I received a call from pre-admission clinic to see a man who is due for elective L total knee replacement - completed assessment, pre-admission and paperwork. Chase up post-op bloods and XRays to see if all were well. Then I returned to discuss ID consult results with registrar and carry out plans as per discussion. Went to talk to patient and explain her condition and tentative management plan. Printed patient information for her.        

5.00pm to 6.00pm - Was just about leaving for the day when registrar called up to admit a patient from ED with a L neck of femur fracture. Did admission and bloods and ordered CT. Waited for registrar to arrive to take over admission and discuss plan. Finally got to leave when all paperwork was settled and handed over to evening ward cover intern to chase up CT for the new patient.

Kudos if you have endured to read up to this point.

And to think that I once aspired to be an orthopaedic surgeon! Thank God that was a brief phase I have long since gotten over. Oh, but I guess that was mainly about the money anyway. =P

Have I told you how much I hate waking up early in the morning? ARGH.