Skincare in Seattle

Ashling McNally

Seattle, in the state of Washington, is a vibrant and lively city built on seven hills, bordered by Puget Sound to the west and the Cascade mountain ranges in the east. Everywhere you look in Seattle, there seems to be either a stretch of waterfront, a steep gradient or a spectacular view of the city skyline. As quoted in the movie ‘Sleepless in Seattle’, it truly does rain nine months of the year there. It is home to Starbucks coffee, Microsoft and Bill Gates, Boeing planes, Jimmy Hendrix and Nirvana. From the 11th January until the 14th February 2011, it was also my home, while I completed my medical elective placement with The University of Washington School of Medicine.

I was placed at Harborview Medical Center (HMC), which was founded in 1877 and has been in its present location on Seattle’s first hill since 1931. It is Seattle’s sole, surviving public hospital, providing high quality medical care to those who are most in need and least likely to be able to afford private health cover. In 2009 alone, Harborview spent $155 million in providing charity care to the homeless, unemployed and impoverished people of Seattle. Much of the funding comes from the privately insured patients that Harborview attracts, as the premier centre for trauma and burns in the Pacific Northwest. It is also a leader in specialties such as neurosurgery and orthopaedics. A large part of the sustainability of HMC, however, relies on the inspiring clinicians who work there tirelessly, and for lower salaries than their peers in the private system.

Harborview Medical Center

Harborview Medical Center

I spent my month at Harborview with the dermatology department. Approximately two thirds of the week was taken up with dermatology outpatient clinics, clerking patients, carrying out procedures under supervision and formulating management plans with the consultants. During this time I saw plenty of ‘bread and butter’ dermatology, like acne, seborrheic dermatitis and psoriasis. Due to the unique nature of the patient population at Harborview, I also had the opportunity to witness plenty of the ‘weird and wonderful’ dermatological conditions, such as secondary syphilis, Hansen’s disease and mycosis fungoides (the most common variant of cutaneous T cell lymphoma). I learnt how to perform punch and shave biopsies, excise epidermoid cysts, freeze benign skin lesions with liquid nitrogen and perform intra-lesional steroid injections. The remainder of the working week was spent on inpatient consults, where I saw patients with conditions such as Stevens-Johnson syndrome and acute generalized exanthematous pustulosis. I also undertook professional development activities, like journal club, Grand rounds and teaching ward rounds.

Dermatology at HMC has a strong grounding in evidence-based practice. Use of bedside diagnostic testing is standard practice, with clinicians taking skin scrapings on slides, preparing Gram stains, KOH preparations etc. and personally assessing the histopathology under the miscroscope. Every Friday, the dermatology staff attends case reviews in the pathology department, where the slides from the biopsies and excised lesions performed during the week are viewed through a teaching microscope and discussed with the pathologists. Careful attention is paid to ensure that practice within the dermatology department reflects the best current evidence from the literature. One patient who made a particular impression on me was a 39 year old HIV+ man with severe pyoderma gangrenosum. He had developed a deep ulceration on his lower leg large enough to place a fist in, with peroneal muscle belly and tendons visible in the base of the wound. Unfortunately, his ulcer continued to advance over the course of the month despite conventional treatment, and the next option was to trial a biological agent to save his leg from amputation. Obviously the risk of causing further immunosuppression in a HIV+ individual with biologic agents could potentially be very serious, so my supervising consultant and I turned to journal databases to evaluate the safety of this option. I will be following his progress with interest via email.

Time away from the hospital was spent exploring Seattle. My friend and I stayed in the University District, where independent cinemas, bookstores and coffee shops abound. No trip to Seattle is complete without a visit to the top of the iconic Space Needle and the Pike Place Market, where the seafood vendors theatrically toss heavy parcels of fish back and forth and you can buy superbly fresh fruit, vegetables and pasta. Other highlights included taking in the city skyline from the deck of a ferry on Puget Sound, seeing ‘Cinderella’ danced by the Pacific Northwest Ballet Company and the irreverent but highly informative Underground tour, where we learnt about the seamier side of Seattle’s history.

Witnessing the inequity of healthcare access in the US has given me a new appreciation of our public health system in Australia. Despite these systems-based and financial restrictions, the altruistic clinicians working at Harborview are passionate about providing excellent health care to all comers, regardless of race, gender, age or socioeconomic status. The dedication of the medical staff, the well-established teaching culture in the hospital and the generosity of the patients made my time in Seattle both educational and a welcome reminder of why I chose to study medicine. Many thanks to the GV Imaging Rural Travel Fellowship that allowed me to have this wonderful experience.

 


Mt Rainier Vista, The University of Washington Campus in Seattle
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Toma and I on the wards at Harborview Medical Center
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Harborview Medical Center
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The view from the third floor dermatology clinic: the Harborview helipad, downtown Seattle and the harbour.
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Buying fresh fish at Pike Place Market
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The view of Seattle city centre from the top of The Space Needle
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The Space Needle
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Sunrise over the University District (en route to work at the hospital)