Elective Testimonial | Alexandra Murphy

Our students avail of highly-prized elective opportunities at home and abroad. These electives allow students to explore in further depth topics of relevance to their degree programme. As part of our summer elective series, medicine student Alexandra Murphy reflects on her time at Washington University Hospital/Barnes-Jewish Hospital, St Louis, Missouri.

Alexandra Murphy I was lucky enough to be chosen to go to Washington University Hospital/Barnes-Jewish Hospital, St Louis, Missouri for six weeks in the summer of 2011 to undertake an infectious diseases elective. I spent two weeks in outpatient clinic and four weeks on inpatient consult teams.

In the outpatient department I saw patients with HIV and AIDs. Their clinical presentations ranged from entirely healthy with no signs and symptoms and CD4 counts in the normal healthy range and undetectable viral load, to those who neglected to take their medications and were infected with disseminated infections and had AIDs defining illnesses.  I learned that HIV is an infection that can be controlled; for many patients it is now a chronic illness.

In clinic, I would clerk my own patients before presenting them to the Attending (the Consultant) and later type up my own notes on the system. In this way we were more involved within the team than would be the case in the Irish system.

The Ryan White programme is a government aided programme that pays for HIV-associated healthcare costs, including free medication, for those without insurance. Ryan White was a haemophiliac who contracted HIV from blood transfusions. He was the first high-profile, white, middle-class, non-drug user and non-homosexual individual, who died from HIV infection.

Prior to his death, the public had viewed HIV as a disease of intravenous drug users (IVDUs) and homosexuals.  Suddenly, the public perception changed; HIV could affect anyone. Many patients I saw were covered by the Ryan White programme, however if they did not keep up their end of the bargain, i.e. attend clinic every three months etc, the cover would lapse until further paperwork was filed.

This meant that if their coverage lapsed and they turned up at clinic, they could not have any blood tests taken. I found the issue of insurance and money to be the most different and frustrating feature of the US healthcare system.

The main groups who were affected by HIV in Saint Louis were African American homosexuals and a minority of IVDUs. This is a very different profile to that in inner city Dublin, where the main groups affected are IVDUs, immigrants and homosexuals.

While on the inpatient consult service I saw a great deal of endocarditis, cellulitis, sepsis...In one week I saw three young men with gunshot wounds that had left them severely disabled and with brain and spinal abscesses.

The most interesting case I saw was one I ended up presenting at infectious diseases grand rounds.  A man with HIV for over 10 years had been restarted on HAART three months previously. He now presented with headache, nausea and fevers. After many investigations he ended up having disseminated histoplasmosis associated with Immune Reconstitution Inflammatory Syndrome (IRIS). After treating his histoplasmosis he still felt extremely unwell, however greatly improved when started on steroids for IRIS. There were unusual manifestations in his case.

I enjoyed the change of scenery during my time in the US, which made giving up my last long summer to do an elective a little more bearable. Over the six weeks I learned so much; not only facts about Infectious disease, but more importantly clinical skills and confidence in my own abilities. I enjoyed the clinical elective immensely and I would encourage anyone thinking about applying to go for it.

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