The Long Delay

Intern year is done. Let us reflect.

The best way to describe my sentiments on residency to date is: one long delay. For three years my life will be on hold and, hopefully, once these three years are over with I will emerge from hibernation three years older, a little smarter, a little slower, and a little more grizzled; ready to live my life once more. Aside from the rapid accumulation of medical knowledge I do not anticipate this experience netting me anything of significance. Which is a shame, because most of it has nothing to do with residency.

Don't get me wrong. I dislike residency as much as the next medical resident. It's just I don't have very good reason to. Aside from my ample complainings already documented, it ain't that bad. Things are busy and the hours are long, but not so long as to preclude a life outside the hospital for those with enough pluck. Unfortunately that life never seems to have taken place. I don't often do the things I like for lack of like-minded friends, don't often spend time with good friends for lack of common interests, and my chastity has never been less questioned. I got no God, no dog, no woman, waning patriotism, and little time or idea where to find these things. I'm not sad or mad, just frustrated. I've got it good -- That is one thing I do know even if I don't always feel it -- but unfortunately blessings don't necessarily a good life make. And so I wait. Twiddle my thumbs a little longer, hold my breath a little longer, futz around a little longer. (Longer with Big Red!) Keep going to work because that's what I do, and keep going home because that's where I live. I wait for the job to reset, friend pool to refresh, and for the time to once again look forward to something.

So that's how I feel about intern year. I did a lot of things, and then I moved on. End of Act One.

At least I got money. Mmmm assets....

A picture from my apartment. If only I had a balcony. Or a little gratitude.

Welcome to the Circus

For my final act of intern year, a grand menagerie! A collection of things that shouldn't be; a hospital of patients that are not sick! Gather one, gather all to the myth, the mystery, the *greatest* show in history; the last month of inpatient Internal Medicine as an intern!

The Man Without Symptoms!
Straight from Bavaria and to our show exclusively, the man without symptoms! Not a single complaint. Not a single problem. Flawless, painless, soreless and completely disease free; solely in need of a complicated CT scan available only in our very own military institution! Watch as he is not only hospitalized, anesthetized, dialyzed, and lesion localized, but also canonized, exorcised, and cannibalized all over the course of a three day hospital stay. The man has no business being here but because no expense is too small and no admission to the hospital too trivial we will admit him for your viewing satisfaction anyway!

The Respiratorical Horror That Wasn't!
Also for your exclusive entertainment a man so sick, so ill, so reportedly toxic and pernicious, you'll be surprised to hear it's *all* fictitious; the man with a COPD exacerbation so stable it's exasperating! His symptoms are at baseline. His oxygen requirement is unchanged. His breathing is unlabored. He looks altogether all too good; but for a limited time only he will be admitted directly from clinic to receive the same care he'd of received at home!

The Woman that Communes with Spirits!
Next. Born with a terrible gift. A young woman scourged by the Almighty with a supernatural talent lain dormant for centuries. Our very own telegraph to another world. The Woman that Communes with Orthopedic Surgeons! She will be brought to the hospital for reasons unworldly, her care will guided by voices emanating from the very ether, and her entire stay will be determined by a presence heard but never seen! Truly, lads, you have not lived until you have communicated with those not living! Commune with the orthopods for just one shilling! *Never* has health care been so thrilling!

The Amazing Record Player Woman!
Imagine now madams and gents: every day the same thing, every day the same thing, every day the same thing. The next poor woman is bound by an inescapable cosmic cycle to call the police weekly raving of impending robbery at the hands of her neighbors. She is captured in an unbreakable celestial loop to be brought to the hospital on a seven day circuit to be treated for the exact same dementia. She will see exactly the same physicians. Decline exactly the same tests. And be discharged to exactly the same home exactly the same way every time; just like clockwork! It's a rotation so accurate you can mark your calendar by it -- I kid you not! And you're in luck with this one, folks, because if you miss this week's show just come back next week for the encore!

The Phantom Fibrillation!
And if that wasn't enough, friends, gather closer as I speak to you of a phenomenon that some say doesn't exist. A phantasm that materializes only to vanish seconds later. A cardiac conduction abnormality that few have ever seen! The Phantom Fibrillation! The poor bearer of this accursed arrhythmic spirit -- a gentleman from our very own town -- is forced to walk the Earth waiting for his next atrial possession. Come awe at the reports from the ER of his shortness of breath. Then astonish as the same ER reports him to be symptom free! And finally astound as we admit to monitor him, test him, and pursue a workup that could just as easily be done at the cardiac clinic anyway! Now we cannot guarantee that the specters will present themselves, but we *can* guarantee that if they do it will be an event you will not want to miss!

The Golden Crap!
But that's not all. No that's not all at all, folks. Don't even think about it -- not a bit! Our very last act -- our very last sensation, the topic of tomorrow's conversation, an aberration of constipation; ladies and gentleman I present to you the Golden Crap! The man has not pooed for days, some say months, possibly even years! Many have tried to disimpact him but some say he is undisimpactable. He will come into the hospital for one day and one day only to have what many believe will be the most expensive bowel movement ever!

(And cue curtain.)

In conclusion: sometimes my life is like a circus. But with less funnel cake.

Cats and Birds and Brains and Things

It's Multi-Discipline Time!

A little bit of everything means a whole lot of nothing. This next month I will practice a little bit of psychology, a little bit of ophthalmology, a little bit of ear, nose, and throat, and I would, were I not taking leave, also practice a little bit of orthopedics but ah shucks I just won't have the time. Practically speaking, however, no one really wants to orient and integrate someone into a team who will only be with you for a week so I will spend most the next 28 days ignored while fondly staring off into the distance.

Even better, though, no pages!

And what's better than that?

No call!

And what could possibly be better than no call you ask?

Two day weekends!

Fantastic. Morale is much improved.

So the Snow Birds are finally making their way south. "Snow Birds," for those of you not fortunate enough to live south enough in this fine country of ours to be familiar with the term, are elderly folk who migrate with the seasons. Generally they only stop through San Antonio along their way further down into the Valley, but some do stay awhile. What that means for us at the hospital, practically speaking, is an influx in patients who have half their medical records inaccessible in the great barren, frozen North. Not terribly convenient. Medical care aside the Snow Birds are remarkable for their migratory habits and ability to always return home regardless what obstacles may come their way. Some say they follow the stars, some say the have an innate ability to tract the global electromagnetic field, others say it has something to do with all the hardware in their knees and hips , but whatever the reason it's pretty impressive. Sometimes we affix clinic notes to their legs with TED hose when the server's down. It's almost as efficient as electronic medical records.

And lastly a cat update. Despite repeated application of moth balls the cat problem has not changed significantly. An opossum has joined their ranks oddly enough -- I would have figured cats eat opossums or vice versa -- but by and large they still generally do as they please. What is new is that the they seem to have taken to the trees. Whether for nesting or roosting or the simple fact that there is simply not enough space for them any longer on the ground, every tree on the street seems to have a cat or two in it. Whenever I come home from work one will inevitably jump down and scurry away for whatever crazy cat reason they have in mind. I would like to shake the trees and see what comes out, but the last thing I need is a cat on my head so for now I will tolerate them. Soon they will move into the attic and under the furniture. At that point hopefully my apartment will be done; I don't expect Laura to make it through the year.

Catz!

My Greatest Weakness is I Care Too Much

Or rather am forced to care -- personally I don't give a damn.

It is perhaps ironic, or perhaps not, that the process of training physicians arouses in its would-be doctors feelings that are often so exactly the opposite of what it is clinicians are supposed to feel. Case in point: coumadin. Perhaps it'll make you bleed out your bottom, perhaps it'll make you bleed into your noggin, perhaps, just perhaps, it'll save your life. Of course that's on a running average over a sufficient time period. For most people it'll just seriously inconvenience their lives and lead to unsightly bruising. But oh the joys of administering it, and ho what greater joys are to be had if the patient cannot competently do so themselves. This last block what did I get to do? Give coumadin! What does that mean?! Well let me tell you.

It means I had to convince the patient that first she needed to start taking Lovenox shots because, you see, coumadin takes a few days to find itself. It's a slow acting drug. Then, once she had conceded, I had to write a prescription for the Lovenox, find out the fax number of the home health company that would take care of her, fax the prescription to them, ensure they'd receive the fax, fax it again when they didn't, ensure receipt a second time, order additional every other day blood testing to ensure medication levels were sufficient, arrange for someone to follow up these levels while I was out of the hospital for the weekend, and then report all of this information to my master and commander for their seal of approval. Then we get to the coumadin. We start with a dose that sounds about right, repeat the prescription writing process above, explain to the patient to take all the dose and not just part of it and that no her belly pain is not due to the coumadin, ensure she has extra different sized pills in case we have to change the dose, and again ensure there is someone willing to follow up the numbers while I am gone. In the days long gone I am told docs had to follow the blood levels themselves indefinitely. Today, however, we have a coumadin clinic. The clinic it turns out, however, has phones that do not work (how terribly convenient?), only has classes on Tuesdays and Fridays, works ridiculously little hours, has an intricate consulting process requiring secret passwords and ancient languages, is closed completely on Thursdays, and seems to be generally run as clandestinely as possible. I almost wish for the good ol' days. The end result of my labors? A woman can live a little longer. Or die a little earlier it's hard to say with statistics. All for 45 minutes of my time and a tiny bit of my soul.

But there are good stories too! Like my colitis patient who kept an intricate record of his diarrhea for me every day in the hospital so that my work was a little easier in the morning. And the illuminated, plastic landscapes hanging in the Intermediate Medical Care Units (IMCU) that make it feel a little less like a dungeon while also suceeding in keeping the patients awake at night. And the dirty old man in clinic who told me naughty jokes while his half-demented wife whom he lovingly cared for cackled on about who knows what in the background.

Internship sucks right now. I hate it. The reasons are varied, some good, some bad, some legitimate, some not so much, but overall it's a demoralizing drain. There are some good times to be had -- though looking over my list the term seems to have become quite relative -- but mostly the best of times are had as far away from the hospital gates as possible. Only one and a half years left before some semblance of a good life returns. Only one and a half years left.

We did go to Six Flags for Fright Fest, though. Lots of fake blood and plastic skulls to be found. Spun around a lot and then had a funnel cake.

And I did finally venture up top the Tower of Americas to the Charter House bar. It was nice. The view was lovely. We went home.

I am feeling ambiguous and muddled. Perhaps it the lack of an appropriate sleep wake cycle.

Excelsior!

Driven to Drink

Another week of clinic and another week of working late secondary to patient problems in the head. This time it was anxiety and panic. An otherwise uneventful morning clinic was made a good 2 to 3 hours longer by the theatrical shenanigans of one young patient who, medically speaking, was freaking out. This manifested itself mostly through exaggerated breathing which was entirely unnecessary as even when we slapped him across the face with some Ativan and his respiratory rate dropped into the range where the rest of us typically like to breath he continued to have excellent oxygen saturation of his blood. Unfortunately, the fact that his oxygen sats and vital signs were pristine were of completely no relevance to him as he continued to complain of anxiety, shortness of breath, and so on. Why did he feel this way? Who the hell knows. He couldn't say. Why was he still complaining of shortness of breath when he clearly was not short of breath any longer? Beats me. He couldn't say. How was this at all in any way different from the panic attack he had had only two months before in the emergency room? *Shrug* He couldn't say. He just knew something was amiss.

Of course there wasn't. He was just having a panic attack and all this was both consistent with panic attacks in general and past panic attacks that he had himself experienced in the past. We'd done a thorough cardiac and neurological exam, even, probably unnecessarily, ordered an EKG and looked into the possibility of a pulmonary embolism of which he had no evidence for, and we found nothing. Unfortunately, I am not yet confident enough in my nascent physician skills to say, "hey, buddy, get out of my exam room already!" and so we gradually titrated his Ativan till clinic ended, my supervisor came in to take a peek, and we gave him the choice to go home or to go to the ER. Next time I think I'll try grabbing his shoulders, shake, and exclaim, "get a hold of yourself man!" Maybe I can get a clinical trial published out of this.

And so now I drink. Not alcohol so much -- I still generally don't care for that -- but I have taken up coffee. These long hours and frustrating patients mean drinking tea three times a day will not suffice. Who wants to drink that much tea? Certainly not me. The alternative caffeinated beverage list included coffee and soda, but as the idea of a cold Dr. Pepper at 0700 did not sound terribly appetizing I decided to turn to coffee. I had never really enjoyed coffee in the past, but it turns out with a couple creamers and a couple sugar packets most things taste better. Unfortunately it seems even the added caffeine boost of 16 oz of generic Wilford Hall coffee cannot sustain my attentiveness any longer than the actual drinking of the beverage itself which makes me think: maybe it's just the act of doing something during lecture which helps me stay awake? Maybe I just need to keep busy somehow instead of passively listening/staring/dozing off? Maybe I should try milkshakes? I'll stick with coffee and tea for now, but if things continue on it may be milkshake time. And after that? A fifth of jäger? A nice club soda?

Internal Medicine with a Minor in Psychology

My clinic doth run over.

Officially each office visit should take 45 minutes of my time. Recently, however, this has not been the case. Instead I will have three or four 50 minute appointments and one drawn out and draining 1 hour and 15 minute one. This is not because I am just that thorough and kind hearted. But rather because my patients all seem to have a touch of the crazy.

Sometimes it's fibromyalgia with the patient reporting pain here, here, and here. Some pain there radiating back to the first here and sometimes becoming the second here. And that place over there has two types of pain. Oh and my hair hurts.

Sometimes it's chronic fatigue syndrome. Or myalgic encephalomyelitis as my patients like to call it. Or yuppie flu as I like to call it. They aren't the actual patients, their sick relatives in need of custodial care are usually who the visit's for, but patients' families can just as often be as much part of the problem as part of the cure.

Then there's the standard old major depressive disorder. Patient wants to kill himself, doesn't want to talk to anyone about it, and doesn't want to leave the exam room. Of course he didn't come in for depression. No, you cannot get a medicine appointment for a psych complaint. Instead you gotta be sneaky crafty. Don't want to ruin the surprise.

And lastly there's the undiagnosed bipolar patient talking incessantly, not answering questions, and generally providing no relevant information about his ailments to do either of us any good. Feel free to leave before I return from consulting with the staff physician about your diagnosis. It's not like you came to the clinic for medical care because, actually, I am still not sure why you came to the clinic today.

All in all it makes clinic interesting and for me leaving the hospital at 1900 or 2000 at night. The immediate frustrations aside I do not mean to convey that I dislike psychiatric patients -- and two of the disorders aren't even psychology related really. Crazy people are people too after all. It is just that I don't have enough time to take care of all the problems which actually threaten life and limb let alone the hours extra needed to take care of the problems brought about by bad humors and forest gnomes. I am training to become an internal medicine physician but to date it seems my end expertise will be that of a psychologist / orthopedist who occasionally dabbles in the diabetes and the common cold.

***As a general disclaimer: though I in general like to try and be an honest guy, with all the rules these days and the rise of the HIPAA fascist state I must resort to vagueness, generalizations, and outright lies when it comes to recounting my patient stories. Don't want to breach any privacy here and I definitely don't want a summary execution without trial.***

Ready, Set, You're Late

One of thirteen blocks for intern year complete.

Thank goodness.

In summary this is what the last month was like. I was given five brief lectures by five different individuals only three of which clearly pertained to my upcoming medical career and only one of which was delivered by anyone with a clear command of the English language (and it wasn't for one of the pertinent lectures.) I was then dressed up in costume, asked to spin around with my head on a baseball bat for two minutes, and subsequently thrown into a task I had spent many years hearing about but not actually pretended to practice to any great extent for over half of a year. They then kept me awake for 30 hours straight and upon my discharge told me I was doing it all wrong.

Ok, so there's some hyperbole there, but I will say overall life has not be pleasant. Of course this was to be expected. It is not intended to be pleasant. And so I keep telling myself this. Thankfully the disorientation and periodic despair are resolving as things settle and become routine. The military did -- in my own opinion and in the collective opinion of the intern class -- a poor job preparing us for the practical aspects of our work in the military setting, and I did a poor job of preparing myself during the fourth year of medical school for the practical aspects of caring for patients. So there's been some catch up. Now, however, the main problems are, and will likely remain, ignorance and inefficiency. It seems I do not know much and what I do know I do slowly. But, as stated before, this is to be expected. Hopefully at some point I will find a way to resolve them. Currently I am thinking more caffeine and perhaps some methamphetamine.

Medicine wards at Brooks Army Medical Center (BAMC) was, with rare exceptions, not fun. Overall I had a good team of resident, attending, and medical students, but I will not miss any of them. Much like Commissioned Officer Training was a hectic, unpleasant, but ultimately educational (sort of) experience, the last month has been a kick in the pants and a kick in the balls, but kicks that were both probably needed. Now it's ambulatory month so four weeks of two day weekends! Few things elicit a smile as much as the idea of a two day weekend does. Either this is an indication that I have found satisfaction in the simple things in life or I currently have only simple things in life to provide satisfaction.

Anyways, life goes on. Good times are still occasionally had. The Olympics are coming up. I am relatively content.

USA! USA! USA!

He Eats Mostly Milkshakes

There are few joys in the life of an intern. One's days consist mostly of recording an endless sum of data, transcribing an endless number of notes, returning an endless stream of pages, and laboring endlessly in the hospital's endless bituminous coal mines. It is infrequent when one can smile and if you smile too long they call it mania and start you on depressants. One consistent joy, however, has always been stumbling upon the curiously written statements of other physicians. (Yes this is what goes for joy these days.)

For medical and legal reasons everything must be documented meticulously. Sometimes, however, well, there just ain't time to do it well. As a result well crafted statements succinctly conveying information are often replaced with whatever thought first enters the physician's mind which, to him at least, conveys what it is he's trying to convey. The vast majority of times this is sufficient. Some of the time, however, it just doesn't quite come out right.

In one recent event concerning an elderly, fatigued patient of ours, the consulted hematologist-oncologist wrote a quick one paragraph statement discussing the nature of the man's pancytopenia. After briefly describing the patient's signs and symptoms in the standard medical jargon he writes in a new sentence, plainly, "The patient states he eats mostly milkshakes." He was trying to convey that the patient was malnourished and so lacking in the vitamins necessary for adequate blood production, but all I could think was, "that is awesome. He really does enjoy his milkshakes." This was, incidentally, a miscommunication -- the patient had informed us earlier that though he did indeed love himself some milkshakes he actually ate microwave dinners from time to time as well -- but nevertheless that's what was recorded and that's what everyone will be forever reading when they go through his medical records. I can only imagine what will be recorded by future physician robots of me. Probably something like, "The patient states he eats mostly sandwiches. Patient perseverates on the idea that he makes quite possibly the best sandwiches in the world discussing the matter at length. Consider psych consult."

Speaking of eating nothing but milkshakes, my diet is actually not too entirely different right now. With no established lunch time and about 14 hours of work for an 11 hour day lunch is often cast aside and you eat what's nearby. Hopefully it's edible. For this last week it's been:

• Sunday: Half day, I made a sandwich. Possibly the best sandwich in the world.

• Monday: On call. 1100 ate some beef jerky. 1300 ate some dried strawberries. 1600 ate grilled cheese, fritos, and a Cherry Coke.

• Tuesday: Post call. 1400 made a sandwich. Possibly the best sandwich in the world.

• Wednesday: Off, I made a sandwich. Very likely the best sandwich in the world.

• Thursday: Normal work day. 1400 ate two bags of fritos and a 7Up.

• Friday: Normal work day. 1400 ate grilled cheese, chili mac, Ruffles, and a Barqs Root Beer.

And that's a good week. The pinnacle so far, however, has been the Tuesday prior when my lunch consisted entirely of a strawberry cupcake. At first I was worried I'd lose weight and become questionably anorexic, but it turns out the caloric intake of cupcakes is about the same as a regular meal. I'll just end up pancytopenic someday.

On a separate note. My long call last Friday resulted not in sixty new patients -- I cap at five new ones in most circumstances and so was done admitting new patients around 11:00 pm -- but it did have about sixty cross cover pages to take care of. I have been jinxed; I have been humbled.

The Disorientation Process

Twenty-one days into the USAF residents and fellows orientation process and still I am not entirely sure what is going on. We have been given a scavenger list of various quests to complete, all usually involving taking a form to at least three different offices only to be rewarded with another form, and have been vaguely made aware of the existence of a second, secret list which must also be completed less we offend the Major General Travis in his omnipresence. When not wandering about the base we are either treated to a series of uncoordinated, often redundant lectures in the WHMC Auditorium, a comfy if not soporific locale, or are sent to undergo a seemingly never ending list of computer training and online courses concerning everything from the dreaded HIPAA to the international human trafficking problem to the proper use of tobacco in treating wounds and disease when trapped in occupied territory. The knee bent scattered running about is further worsened by the general lack of clear headship in the orientation process and the frequent ignorance of those who seem like they should know. It is not uncommon -- and in fact is the norm -- to receive multiple different answers to the same question depending on who you ask. This is not to complain about the individual efforts of those immediately involved, they've certainly tried to be helpful, but rather the seemingly complete lack of planning and foresight in the construction of the orientation process by whoever it was that was in charge of it. Alas, it seems planning and foresight are not common traits at certain levels of the armed forces so I suppose the orientation of one hundred plus physicians in the largest medical training program of the Department of Defense should be no different. Thankfully waiting weeks for moving boxes because they have been put in storage, waiting three plus hours for a simple CAC card, and driving thirty minutes each way to attend mandatory picnics are all made at least a little bit more tolerable by the fact that we're at least getting paid for the tomfoolery. Paid too much of course -- and that money will be paid back lest you be prosecuted as an enemy combatant under the ICMJ -- but paid nevertheless.

Orientation has had its good points. My fellow internal medicine interns seem to be good chaps all. Weekends have been completely free. Most people have been graciously kind with our collective ignorance. Other things I undoubtebly simply cannot remember right now, like, I don't know, cheap Time Warner cable at the BX are nice too I guess. It's just that, three weeks later, the only thing I am confident about is that I have not done everything that has not been asked of me. The prolonged time for orientation was supposed to give us ample time to take care of life's problems so we could be ready to focus on internship. Well, they've done that, but instead handed us a list of military-based headaches in exchange.

Speaking of internship. I am about to do this thing in a little over a day from now. There is some anxiety, a little bit of fear, and a whole lot of, "let's get this the hell over with already." Orientation was the finishing exclamation mark to a whole year of silly things which generally speaking had nothing to do with medicine. It was delightful, but I am now ready to do the real thing. As long as someone holds my hand of course. And it is knowledge that there will be that someone, indeed a whole chain of someones, that gives me confidence that though I will surely mess up a hundred times over there will be people to protect my patients from me. I am not happy that my life will be essentially nothing but medicine for the foreseeable long term, but, really, my life was not terribly exciting to begin with. At least now I will be smartening myself and saving lives in the process, at least on average. So overall things are changing and change is scary but not when the change involves things I mostly don't care much about so, in conclusion: orientation with the air force is wacky; life goes on.