IER Placement: Infectious Disease

As part of the McMaster Physician Assistant Education Program curriculum, each student shadows a professional in the field relevant to the unit being studied that month. These are called IER placements and students are assigned a half-day shift at a hospital/clinic in Hamilton. IER stands for Interviewing, Examining, and Reasoning.

For this IER Placement:

  • Medical Foundation Unit: Infectious Disease
  • Professional Shadowed: Physician Assistant
  • Date of Placement: Friday, May 1, 2015
  • Where: Toronto East General Hospital

Read more about what I learned in my placement!

Infectious Disease

Infectious disease is one of my favourite units. I like learning about the different pathogens and what pathological conditions they can cause. At the same time, I’m worried about my own health…what if I get infected myself?? This was a concern of mine until I knew more about infections and infection control.

We got the whole Infection Control Education Session at the Juravinski Hospital. Healthy people with an intact immune system and who practices good hand hygiene will not get infected that easily. After this unit, I definitely am more self-aware about using alcohol-based sanitizers after every patient interaction, before eating…making sure I rub it in my hands for the full 15 seconds.

Personal Protective Equipment and Different Precautions

Precautions are interventions to reduce the risk of transmission of microorganisms. Precautions need to be taken when interacting with patients. Not only are we protecting ourselves, but we are also protecting patients who have a weak immune system…which is almost everyone in the hospital.

TREAT EVERYONE AS IF THEY HAVE A BLOODBORNE INFECTION

Hospital Acquire Infection is the 4th leading cause of death in Canada (after Cancer, Heart Disease, and Stroke). Where do patients get HAP from? Direct contact from health care professionals and contaminated medical equipment.

Put them PPEs on!

Hand hygiene is a must! Do it:

  • Before interacting with patient
  • Before antiseptic procedure
  • After body fluid contact
  • After leaving patient environment/contact
  • After using washroom
  • After blowing nose
  • After eating
  • Anytime hands are visibly soiled –> use soap and water!

Additional precautions are needed when hand hygiene is not enough! There are some bad bugs out there…

  • Droplet precaution = for patients with respiratory secretions
  • Contact precaution = for patients with resistant pathogens (MRSA, VRE, ESBL, C. diff) or blood, body fluids, excretions (vomiting, diarrhea) and secretions (pus)
  • Airborne precaution = for patients with suspected/confirmed TB, Measles or varicella

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Seeing Patients

Cellulitis

  • This patient that we saw is a woman about 45 years old who presented with an erythematous rash on her abdomen that started that morning. On examination, it is a raised lesion, warm to touch and appears to have spread to a larger area. She was diagnosed with cellulitis.
  • Cellulitis can present with a lesion that looks like an orange peel/skin
  • Cellulitis is a bacterial skin infection. The most common pathogens that cause skin infections are Staph aureus and strep pyogenes. So the antibiotics ordered covered both these groups. It’s hard to culture the bacteria responsible for cellulitis since 1) staph and strep are found normally on our skin and 2) it will take days for the culture results to come back.

Methicillin Resistant Staphylococcus Aureus

  • Staph. Aureus is a gram-positive bacteria. Most of them are resistant to penicillin because they secrete penicillinase (an enzyme that breaks down penicillin….so there’s not point in giving someone with a staph aureus infection penicillin if the penicillinase will just stop it from working)
  • Methicillin, Nafcillin are NOT penicillins, so these are our second line antibiotics
  • The scariest of them are Methicillin Resistant Staph Aureus or MRSA. It is a strain that acquired resistance to methicillin and nafcillin. They tend be to be developed in hospitals where broad-spectrum antibiotics are used. It is transferred from patient to patient by hand contact of health care workers (PREVENTION: good hand hygiene + the health care worker should gown up if the patient is known to have MRSA…this can prevent spreading MRSA from this patient to the next patient)
  • Vancomycin is one of the few antibiotics that can treat infections caused by MRSA. It is one of the big guns in antibiotics. We try to save this for serious infections, just because a lot of pathogens are becoming more resistance to first-line antibiotics. We don’t want to overuse it though or else these bacteria can become resistant to it as well…and then we won’t have any weapons against MRSA.

Red man syndrome 

  • If vancomycin is infused too fast, an infusion reaction known as Red Man Syndrome can occur. It’s not an allergic reaction. Just that infusing vancomycin too fast can cause mast cell degranulation –> histamine release –> causing leaky vessels –> pruritis, erythema on skin
  • One of the patients we saw had this reaction, but the staff did not know if it was an allergic reaction or Red Man Syndrome. They asked a pharmacist to come in to watch a supervised vancomycin challenge to see if it is a true allergy (anaphylaxis) or just Red Man Syndrome.

C. diff

  • C. diff can cause a severe form of diarrhea. Our colon has good bacteria that keep the bad bacteria (like C. diff) from invading our mucosa. When patients, especially those in the hospital, take broad spectrum antibiotics for a long term, it kills not only the bad bacteria but the good ones as well. With not enough time for the good bacteria to replenish the colon, the bad bacteria take advantage of the weakened defense and infect the colon!
  • C. diff releases toxins that cause inflammation in the colon, allowing fluid to be lost. It also releases another toxin that kills colon cells

  • Patients with C. diff can shed the bacteria in their stool, which can infect hospital staff and other patients. (PRECAUTIONS SUPER IMPORTANT HERE to prevent transmission…GOWN UP!)
  • Diagnosis is made by stool investigation for the toxins
  • Treatment includes stopping the antibiotics to allow the colon flora to replenish, IV fluids (rehydrate patient since they are losing fluid through diarrhea), and metronidazole (Flagyl) ORALLY if patient has fever and severe abdomen pain. Flagyl is an antibiotic but when taken by mouth, the medication goes straight to the colon lumen to attack C. diff and prevent it from growing.
  • One new treatment for recurrent C. diff infection is Fecal Microbiota Transplantation. The purpose is to recolonize the patient’s colon with bacteria from a healthy person via the healthy person’s feces. Read article about FMT procedures down in Hamilton by Dr. Christine Lee.
  • And guess what? They’re training dogs to sniff out patients who have C. diff

Overall Experience

I enjoyed my placement at Toronto East General Hospital. I think learned a lot from the physician who quizzed me on my knowledge. Other than the cellulitis case, the other patients were follow-ups or awaiting tests…so I did not get to see much there. However, I think infectious disease is a very interesting area of medicine. It’s like detective work, trying to find the culprit (pathogen) and killing it with the right antibiotic! (my analogy here is quite simplified!)

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