Behind the White Coat

Pyoderma Gangrenosum

I thought I have seen some nasty and distrubing things in the past two years, but there is always something that comes along that makes me cringe and wonder how some of these patients deal with their disease.  I admitted this lady with a  diagnosis of Pyoderma Gangrenosum . It is a chronic ulcerating rash that occurs from a specific type of dysfunction in one's immune system, which causes necrosis and eating away of the skin to various degrees.  It usually ocurrs in the legs, but occasionally can afflict other body parts.  This young lady happened to have it on her head.  Now if one takes care of it, and takes the right type of immunsuppressive medicine, you can keep it controlled and at bay.  However not taking the medicines and not taking care of the wounds can lead to worsening of the disease, necrosis of a lot of skin, and just eating away of the tissue.  This lady happened to be in the latter category.  She has a long history of cocaine and heroine abuse, and doesn't really take care of herself, or take her meds, and always gets a superimposed infection of this wound.   

When I first saw her she had her entire head wrapped in gauze, and all I could see is were her bulging edeamatous eyes, which were also infected from the skin into the eye itself, so they were puffy, red, and grotuesquely distorted.  I thought this was bad.... but then we unwrapped her bandages (which had to be done after giving her morphine for the pain).  It was disturbing.  There was a clear demarcation between where the disease began.  Her face from the forehead to the chin, and across to where the eyes ended seeemd relatively intact.  Everywhere else, the skin was eaten away.  The whole head, sides of her face, ears, everywhere was just inflammed, red, necrotic tissue with pus, and we could almost see her skull at certain points.  One patch of skin maybe 1cm squred remained on the back of her head with some hair, everything else gone. Her ears were eaten away, leaving little vestigal like structures. Apparently when she was here last month, there were maggots crawling across her wounds,and there was almost a hole through her cheek because of the necrosis.

I don't know how this lady is still alive, or how she deals with this, but I feel for her.  What a terrible way to live, and the drug abuse only fuels it, which will never cease despite all the interventions that have been tried.  Though if I were in her shoes, I probably would have resorted to wallowing in my misery with a life of drugs as well.  The combination of the two will likely cause her a painful, infective, disgusting death.  She is only 36.

Another Day in July...

Has it really been that long since I posted?  Wow, July really flew by quick....  Probably because I have been at work most of the time, and come home to eat, watch some TV, and pass out. Waking up at 6am and getting home at 7pm on non-call days is tiring.   As expected, it has been a busy month working with the brand new interns:  new doctors who were wide-eyed medical students not even a month ago! They  pretty much ask me before they do anything in fear they will kill someone with one dose of tylenol. I suppose it is better that way until they know what they are doing.  Nobody has died a horrible death as yet, and no malpractice has ocurred, so things seem to be doin well!  But like I said, avoid going to the hospital in July at all costs!!

This past week we've had all these crazy old stubborn demented women on our service.  They may be 90 and demented, but they are feisty.  They like to roam hallways hunched over w/ a cane, and scream and attack people.  One lady told me to kiss her ass and dug her nails into my skin while I tried to get blood from her - I think it's goin to leave a scar.  Another 85 yr old lady would just moan and scream all night, and tell us we are "no good", and throw things staff. We had to literally kick her out of the hospital because nothin was wrong with her.  I think in my living will I am goin to dictate if I ever become a combative demented old person, just put me out of my misery.

Alright, nothing exciting to report today aside from the usual sick people with sepsis, heart attacks, COPD, diabetes, metastatic cancer, combative dementia, and of course, infectious diarrhea.

July

So it is July, and a lotta things have gone down... For one I am now a 3rd year resident.  The final year of residency, where I am the senior, and will probably have to exercise more responsiblity, knowledge, and mentorship, which is kind of nice.  In a way I'm also a "lame duck" resident, since I have matched for my cardiology fellowship at North Shore.  But I must say I do enjoy general medicine, and I will miss a lot of it when I do cardiology, so I feel I should live it up and do as much learning, teaching, and everything else that I can! 

I ended my second year with vacation as I had said before, my cousin's wedding, and then the final 3 days I spent in Vegas.  The interns at our program usually go to Vegas at the end of their first year, and luckily I had vacation, so being the unofficial social chair, I deemed it necessary for me to go with them!  Myself and 2 other seniors rolled, and man it was fun as hell... We stayed at the Venetian, partied it up, and had a blast.  I won about $200 (measely I know, but at least I didn't lose!), but spent a shit load more... The pics are again on facebook, so checkem out!

Now I have started back on the medical wards (one of three months this year).  July is a crazy month to be on the wards, because all the interns are brand new!  I started the day after I got back, and barely slept in vegas, and have barely slept this week!  It has been busy.  Nobody knows what the hell they are doing, so I have to double check everything and hold their hands... Was I this slow and incompetent as an intern? Who knows... Anyhows, at least none of my interns cried, because I saw one balling in tears the 2nd day!  Luckily so far, there has been no malpractice on my service... I advise you all to not get sick this month, because you'll be taken care of by rookies!!  More medical stories definitely to come this month, so stay tuned...

Today I went back to NJ for a bbq at the 'rents house with some fam and friends. Good times. So as I am heading in after work around 3, I go into town to get some beer and chips.  Of course I am speeding, 51 in a 25, and I get pulled over!  Fuck.  It's been ages since the heat got me.  I quickly put on my ID, and throw my stethescope on my lap to let him know what I'm all about.  Will the doctor card work? I hoped so.... So the cops rolls up, surly bitchy looking guy, and takes my license and registration.  He asks for my insurance, and as I look for it he starts asking me questions.  I tell him I'm a doctor in the Bronx, back for a BBQ, and yes I have lived in Tenafly all my life (I haven't for years, but my license says he does).  He asks me why is my steth in my lap, and I slyly answer it was on my neck but I just took it off... Meanwhile I couldn't find my damn insurance card!  He asks me what am I doing, and clearly there was no front for an emergency, and I said I am coming back from work, and going to get some tortilla chips for the bbq.  Stat.  He starts going off on speeding blah blah blah, and is pissed I don't have my insurance....  Finally he gives in and lets me go, and tells me to get my insurance card and not to speed, and that was it....  Nice.   That woulda been speeding AND reckless driving for doubling the limit!  Looks like this doctor thing paid off!  I went on my way, and that was it....  Gotta love it.