Rotation #3 Kaiser Oakland Medical Center

Last week I started my third and final rotation of 2015 at Kaiser Oakland. I was pretty excited to start this rotation as I've always been really interested in Genetics ever since I learned about it as a freshman in high school. Having a background in Molecular Cell Biology and some in Human Development and Embryology is a definite plus for this rotation too.

So far, I'm enjoying being at Kaiser a lot. In a short week, I've seen a number of diseases and syndromes that I was constantly studying about during Step 1 and Step 2. If I was on a different rotation, I might very well have never seen any of these cases. Some of them include things like Neurofibromatosis 1 and 2, Tuberous sclerosis, Klinefelter's, Ectodermal dysplasia, and kids with Arnold Chiari malformations and myelomeningoceles. It's a lot to take in but the best part is that there's enough free time for me to research and brush up on everything while I'm at the hospital. It makes learning and remembering the diseases that much easier when I can correlate real life to what I read in the textbook or on the internet.

It was a gloomy day today in Oakland with a little bit rain!

What I love about genetics is that you have to know about all the organ systems that a disease can involve. For example, tuberous sclerosis can often involve the brain, the eyes, the heart, and the kidneys so making sure that the kid has good follow-up with the specialists is a really important part of disease management. I also really like that in genetics, you can advise patients on the risk of passing a certain condition onto their offspring. However, that's also one of the most frustrating things about genetics as well. As much as science has advanced in the last 100 years, especially in the field of molecular genetics and genome sequencing, a lot of the current laboratory tests for human gene sequencing is still far from adequate. Occasionally, the result of gene sequencing shows that the patient has a specific, documented mutation in the exact gene you suspected. For example, if the test for Cystic Fibrosis shows the classic delta-F508 mutation in chromosome 7 then you can practically be 100% certain that the child has CF. Unfortunately, often times, gene sequencing will come back with a result of something along the lines of "variant of unknown significance" which basically means that we don't know if the mutation is pathogenic or not. It could very well be that the specific allelic variant is a completely normal one or it could be that the variant is in fact causing the disease. When that happens, it's really hard to tell the parents that essentially we did the test and now we have this information....but what can we do with the information? Essentially not that much.

A ton of research is going into genetics as it's still one of the biggest subjects in science. There have been leaps and bounds made in the last 50 years in the field but there are many more breakthroughs that must arise before genetic testing will become more helpful. It's truly a field that has so much more potential ahead for it and one that many more people will continue to utilize as research and further medical advancements are made. If I decide to go into genetics, one thing I'll know for certain is that it will never be an obsolete field....and that's pretty reassuring!

Rotation #2 Lucile Packard Children's Hospital

Lucile Packard's Children's Hospital at Stanford University is unlike any other hospital I've ever been to. It's perhaps one of the craziest tertiary care centers in the world. During the time I'm spending here, I'm doing a Pediatrics Nephrology Rotation. What's different about this rotation for me, is that I interact mostly with fellows and Attendings instead of residents...and to some degree, this is what makes the rotation a bit harder for me. Fellows are two steps away from medical students and Attendings are three steps away. I'm used to helping residents out or even sometimes acting like an intern. Fellows though, have already completed their residency years and are now going on to subspecialize in their fields. In short, there's not much that I can do to help a fellow out and I certainly can't act like a fellow if I haven't made it to residency yet.

Nephrology is a crazy field. Pediatrics Nephrology is even crazier. You get to deal with all the congenital kidney anomalies that occur in utero (while the baby is still developing in the mom's uterus) or other kidney concerns that arise when the kidneys take a hit from difficulties during delivery or as the baby is growing older. One of the main problems that lead to the kidneys taking a hit is when there is severe blood loss, or hemorrhage. Examples: a placental abruption during delivery where the placenta suddenly breaks away from the uterus. When this happens, suddenly you lose the blood exchange that's supposed to be carrying mom's fresh blood which contains oxygen and nutrients to the baby. In addition, now you're also unable to return blood that contains waste metabolites from the baby back to mom for filtering. The placenta abruption can further cause hemorrhaging in both the mom and the baby. In an effort to preserve blood flow to the two vital organs of the body, the brain and the heart, the body naturally shunts blood away from other organs such as the GI tract, your extremities, or the kidneys. The result is that even if the baby's kidneys developed normally, a sudden traumatic event can cause life-changing consequences. 

                                    

A good majority of the Pediatric Nephrology patients at LPCH are incredibly complex. Not only do we see kids with kidney problems, we also seem to see a ton of kids with kidney and GI problems. A large part of this is that kidney issues cause a variety of other problems including but not limited to  electrolyte imbalances, feeding issues, blood pressure changes, and the most basic growing concerns. At best, the kids get a kidney transplant and hopefully live another 10 to 20 years, at worst, they pass away before a donor kidney becomes available. It's entirely a giant spiral downwards which rarely ends well.

LPCH is also the first hospital that I've visited where several of the subspecialty services have their own ward patients in addition to consult patients. From what I've seen so far, it makes on-service weeks incredibly tiring, having to be the point team in charge of your own ward patients as well as having to round on consult service patients every day. It's so miraculous that the fellows and Attendings are able to keep up with all the patients and keep the events of the day straight. Just five days of service is enough to make anyone completely exhausted!

On my last two inpatient weeks I've seen incredible medicine taking place. Events are happening inside Lucile Packard's that simply does not occur anywhere else in the world, including other top Children's Hospitals in the United States. I have two more weeks of Pediatrics Nephrology which I'll be finishing off in outpatient clinic and I hope I'm able to learn a little bit more on my next two weeks here.

Roommates

For the first three years of medical school, I roomed with an awesome person. By some random stroke of luck (or the fact that we both liked cats - and that she had a cat) we were pretty happy being roommates. Eventually, the start of fourth year meant that we finally had to break apart from our comfortable living situation. I decided to move back to California for the large majority of this year while she returned to her home in the suburbs of Chicago. My roommate is probably one of the brightest people in my class and there's no doubt that she'll be awesome at whatever she ends up doing. Fortunately, I happened to get by medical school doing pretty well too so between us, we generally have some pretty intelligent discussions. Every so often though, some funny conversations arise: