History and Physicals:

Typhon Report:

Site Visit Summary:

Site visits were thorough, broadened my perspective, and was a great learning opportunity. During these site visits, I learned about different terminologies used in long-term care (LTC) and how management is geared differently toward the elderly. During these one-on-one site evaluations, I learned more about innovative research on PTSD and other war-related diseases/ conditions. The site evaluator ensured that I understood the difference between LTC history taking, management, assessment, and planning. The site evaluator also asked multiple questions that questioned and strengthened my knowledge of treating geriatric patients and caring for palliative/hospice patients.

Case and Journal Summary:

Case: Mr. FC is a 73-year-old wheelchair bound AAM LTC resident with pmhx of debility, CKD, chronic PTSD, Insulin dependent DM type 2, urinary incontinence, HIV, HTN, former ETOH abuser and former IVDU (Crack/Cocaine) for 12 years who was previously living in the Bronx community alone with frequent case worker visits. Due to his chronic PTSD and debility the resident was admitted to the LTC. Currently the resident is not receiving any treatment for his PTSD.

Journal Article: Surís, A., Smith, J., Powell, C., & North, C. S. (2013). Interfering with the reconsolidation of traumatic memory: sirolimus as a novel agent for treating veterans with posttraumatic stress disorder. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists, 25(1), 33–40.

Summary:

Interfering with the reconsolidation of traumatic memory: sirolimus as a novel agent for treating veterans with posttraumatic stress disorder is an article published in the 2013 Annals of clinical psychiatry. Suris et al., performed a double-blind randomized placebo-controlled trial to study the use of sirolimus to potentiate the effects of specific trauma memory reactivation in managing and treating chronic PTSD. They predicted that pairing a single dose of sirolimus with memory reactivation would reduce the frequency and intensity of PTSD symptoms in 1- and 3-months post-treatment and reduce the intensity of trauma related physiologic responses to trauma memories. The researchers studied a group of 54 participants from a large Southwestern VA medical center that have chronic PTSD and are currently not receiving any other medical treatment for PTSD. The sirolimus group was made up of 27 participants and the control group had 24 participants. Both groups were followed for 3 months in total. The effectiveness of the pairing was evaluated using the Clinician-Administered PTSD scale (CAPS), PCL, and QIDS-SR assessments that was given pre and post treatment and traumatic event reading. A 20 point difference in CAPs from before and after scores was considered a clinically symptom improvement.  The groups were then placed into subgroups of active during Vietnam-era participants (17) and post-Vietnam era participants (34).

Suris et al., found that there was a clinically symptom improvement observed in 40% of the sirolimus group compared to 16% in the control group at 1 month follow up. However, the difference was non-significant at the 3 months. In subgroups, there was no clinical or physiologic difference in Vietnam era participants. In post-Vietnam era participants, there was 47% clinical improvement in the sirolimus group compared to 20% in the placebo group. In both subgroups, there was no significant differences at both 1- and 3- month follow up assessments. This pilot study had several limitations such as the small sample size that decreases the statistical power and optimizing the timing of the medication. Sirolimus reaches its peak levels 1 hour or more post-administration, but the reactivation of the memory began right after administration and lasted about 45 minutes on average. Therefore, the effects of the sirolimus were not actually paired with memory reactivation and could not have a proper reaction to the trauma.

All in all, the advantage of coupling sirolimus with memory activation remains elusive. Suris et al., found that the use of sirolimus was more effective in the younger post-Vietnam era cohorts due to the trauma memories being less chronic and more amenable to modification. They also found that older traumatic memories are much less susceptible to pharmacologic blockade of reconsolidation. Further research needs to be completed to see if there is a benefit to the pairing. In the experiment by Suris et al, the effects of sirolimus diminished after 3 months, further investigation needs to done on whether multiple doses with repeated pairings would reduce PTSD symptoms overtime more than a single dose.

Rotation Reflection:

My sixth rotation was at St. Albans Community Living Center (CLC) for Veterans. The CLC has outpatient clinics, a long-term care home, and a palliative/hospice care facility that houses most veterans from the Korean War and Vietnam War. The community served in the CLC is diverse with about 45 percent African American and Hispanic residents. My sixth rotation was distinct from all others as it changed my perspective on geriatric, long-term, palliative, and hospice care. I had the privilege of rotating through a predominately hospice/palliative care unit, long-term care unit, outpatient and inpatient wound clinic, and other services such as outpatient audiology and with a speech-language pathologist.

During my rotation, I learned how patients in the CLC were called residents. I found that interesting and difficult to do as I have been wired to call those receiving treatment or medical assistance as patients. However, learning the reason why patients are called residents due to the CLC being their home and that they are called “residents” for respect, I quickly adapted to the change. In the LTC and palliative/hospice care unit, multiple residents have mental disorders and other neurologic diseases such as PTSD, Dementia, Parkinson’s, Depression, etc. These residents are some of the nicest people I have met who are willing to share their experiences and let clinicians examine them. And I have seen these exact residents become argumentative or combative due to their PTSD being triggered or their dementia progresses. This allowed me to learn how to differentiate an individual’s personality from their actions in terms of mental health. LTC is not easy and requires patience, proper communication, and compassion for the residents.

During my rotation, I had the opportunity to learn and do wound care. Wound care is paramount for residents with decubitus ulcers, venous insufficiency, and other vascular problems. Seeing how the wound care nurse dressed the wounds and advocated for the residents, taught me to do the same for my future patients. It also taught me that medicine is a group effort that requires all parts of the group to participate and take care of the residents. I did not think I would enjoy this rotation as much as I have. The LTC rotation opened my eyes to what proper and adequate care for geriatric patients is and how broad of a field geriatrics is. All clinicians and nursing staff at the facility were kind and had the spirit of teaching. I enjoyed my time at St. Albans CLC and look forward to my next rotation: Urgent Care at StatCare.