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Saturday, October 31, 2015

The Sepsis Secondary to UTI

The Case:
A 67 years old male with bilateral obsrtuctive nephropathy secondary to nephrolithiasis s/p bilateral ureteral stenting, followed by nephrostomy on the right due to stent failure done a week back now presents with one week of subjective fevers and chills as well as overall weakness and not feeling well.
Vitally stable but tachycardic. Lab work shows leukocytosis with neutrophilia. UA shows >50WBC, 2+ leukocyte esterase, and many bacteria. 
Chart review shows previous urinary cultures not showing any growth.

So this is a typical case of sepsis secondary to UTI. Patient met the criteria of sepsis as he had leukocytosis, was tachycardic and possible source was the urinary tract. 

The patient was put on IV hydration and was started on Ceftriaxone. Urine culture was growing gram negative bacilli and one set of blood cultures was growing gram positive streps.

The things that I learnt from this case were as follow:

The Urinalysis:
Urinalysis is something all patients get in the ER and is rather ignored most of the times as now a days, a culture is drawn almost automatically and we the residents ignore the UA waiting for the culture. It seems like in previous days, in some, if not most hospitals, there would be a lab next to each medicine unit/floor and residents would do certain tests like UA and sputum microscopy themselves. Any of the parameters that are reported as + are actually dipsticks and as per my ID attending are pretty much useless in determining if the patient has UTI as the on going infection or has some other infection going on. The reason being that many conditions other than UTI can give you those positive results.

Nitrite can be positive on dipstick in pretty much any infection if it is severe enough. There is production of NO in sepsis due to any infection which is excreted in the urine as nitrite. The single most important value in the UA is the WBC count done under the microscope, which if high, there's most likely a UTI going on.

The choice of antibiotics:
Ceftriaxone as a choice of antibiotics while the patient is admitted is a good choice and most patient would respond since it has good activity against gram negatives which was the most common causes of UTI, The problem though is that it does not reach very high levels in the urine since it is excreted mostly through the liver and thus can lead to billiary sludge. But most patient's would respond. But if the patient had some kind of instrumentation in place in the urinary tract, quinolones might be a better choice. Mainly because they reach very high concentration in the urine. Even though now in some areas, there's up to 60% resistance to quinolones, their concentration in the urine is so high that they are still effective. So even though this patient responded well to ceftriaxone, quinolones might have been a better choice because of the stent and nephrostomy tube placement.

The bug growing in blood culture:
So the preliminary report said that there is gram positive strep growing in one set of the blood cultures. The fact that its one set could be because of two reasons. It is either a contamination or the bacteremia is small and the number of bacteria isolated are not enough to lead to significant growth in the culture. We concluded it was a contamination and decided to monitor the patient while he is on ceftriaxone. If it is coming from the urinary tract, it is most likely Strep fecalis. We decided if the patient develops fever again or if the repeat culture is positive as well, will switch to Ampicillin from Ceftriaxone since Ampicillin will cover both bugs.


Tuesday, October 13, 2015

The Subtle Bias (or racism?) against IMGs

Life of an IMG is full of many struggles and experiences. After going through USMLEs, visa issues, cultural barriers and shocks, the last thing we want to deal with is a nasty attitude from our attendings or fellow residents just because we are foreigners. After talking to many fellow IMGs, and even a few American graduates, I have concluded that despite all the political correctness in America, some among us cannot hide our feelings towards IMGs.

There could be many possible reasons, first and foremost is just human nature. Be it third world or first, we humans will always be reluctant to let others in. Someone said that AMGs probably hate IMGs because AMGs usually have huge college loans while IMGs mostly don't, so they think they have had to go through all the financial struggles and then we come take over some of their positions and eventually end up making a lot more money than them. It makes sense to a certain extent but our struggles, be it different than theirs, are also very tough. To get into the residency, we have to work a lot harder than our fellow AMGs. Most of us have a very different medical education and healthcare system in our countries and we have to re-wire our brains for the USMLEs,. Not to mention the language and cultural barriers we have to overcome. While the AMGs have it easy in that way. They pretty much work as first year residents in the last year of their medical schools. So for us, it's a switch of not just a country or healthcare system but of an entire lifestyle. I believe we deserve a little more credit and appreciation than what we get most of the time.

This Hispanic medical student from NYU once told me that it is not the bias against IMGs but the general attitude of people in residency programs specially in well known programs. In his words, the attendings yell at the residents, the residents vent it out on their interns and the interns on the medical students. Probably because residencies are "supposed to be" tough and they want to keep it brutal (for whatever reason that I will never understand!). That might be right to a certain extent, but that will not explain why certain attendings have different attitude towards AMGs and IMGs when they are in the same group.

I think not much can be done here regarding the issue but what will help is for IMGs to understand that it's nothing personal, but just human nature about not being trusting someone who is basically from the outside, or sometimes because of just plain ignorance and a result of one's own insecurities, what we can do is to be courteous and professional, and prove with our medical skills that hey, I might have an accent but my patients are as happy as yours if not happier. The AMGs should also understand that IMGs have had to deal with a lot more than what they have had to to get where they are and that kind of determination needs some respect. Both should not forget that we are in the business of saving lives, compassion and patience are what define us, we should practice the same with our colleagues as well, regardless of their nationality or race.

Thursday, October 8, 2015

First time in America, cash or credit?

So I had to face the issue when I first came to the US for my CS exam, just like most of us do. I had brought a few grants in cash but I didn't feel comfortable taking it around or leaving it behind specially when I was living in the hostel like situation. I had the option to use credit card from back home (which I did and later found out that it wasn't the best thing to do) but most of the time there is the international transaction fee and then your bank might not give you a good conversion rate. So if you would prefer carrying a card instead here is the solution: A secure credit card!

So a secure credit card is basically a debit card, the limit of your spending depends upon how much money you are willing to deposit in the account, so whatever you spend is deducted from that accout immediately but it works as a credit card. Now some of you may ask why not get a debit card instead, which of course you can. But the benefit is that this secure credit card will help you build some history with the bank and after a year, most banks will give you a regular credit card. I'm told this secure card also contributes to building your credit score. Many banks offer such a card regardless of your visa status. I got my first one from Bank of America. A friend of mine got it from Chase. So I think many, if not all, banks would offer a version of such a card. Now keep in mind, the money you put in the account cannot be drawn unlike a debit card. In my case, Bank of America refunded the money a year later along with issuing a regular credit card.

If you really don't want to deal with a bank but still want to use a card, you can buy one of those prepaid Visa cards. They can be found at most departmental stores and pharmacies like CVS, Duanereade etc. I bought one from Walmart but I realized it was a bad idea after I found out about the secure credit cards because the prepaid card doesn't give you a credit history and you are bound to spend it since you can't do anything else with it.