I'll Save You!

About a year ago I partook in the military's Combat Casualty Care Course also known as "C4." A week long academic and field training course designed to prepare us for combat medical care as it is provided in the first and lowest echelons of care from the battlefield itself to the first triage and staging areas such as the Forward Operating Base (FOB). In summary: it was cold. The rest of the details I may or may not eventually get to later, but first a story.

Much of our practical field training consisted of forming up in our platoons (see below) and undergoing marches which would take us into various situations where invariably someone's legs would be blown off. Each platoon was broken down into four security teams (X1-4) which provided security and two litter teams (L1 and L2) which provided the actual medical care, collected blown off limbs, and carried the stretchers. All teams had individual leaders (marked by *.) The entire platoon itself was additionally headed by a platoon leader (P). A march would begin in two columns with two security teams in the back and two in the front, the litter teams dispersed somewhere in the middle. It would inevitably end with the litter teams running about in varying degrees of order or chaos while the security teams provided some degree of perimeter cover -- or, as in this last case, just watched the mayhem with an amused curiosity. The missions always changed in detail, but they always consisted of a march to an objective, an attack by our various training instructors (TIs) on the platoon, and people getting their legs blown off.

X1 X1 X1 X1* L1 L1 L1 L1* X2 X2 X2 X2*
P
X3 X3 X3 X3* L2 L2 L2 L2* X4 X4 X4 X4*

Two columns of two security teams and a litter team each form a platoon. Or a bunch of random letters.

After the initial orientation and a few dry runs where we mostly just stared at each other in confusion, the majority of our exercises went off relatively well. The first where I was leader of litter team one was uncomplicated thanks to my impeccable leadership skills and, more likely, simple luck and good fortune. The latter exercises also went off without too many casualties save one surgical intern who had a helmet dropped on her head after stepping on a land mine. The helmet was real, the mine just covered her entire left side in red dust which would never come off. Our second mission, however, was a colossal failure, but for those who were there watching it all unfold as part of the perimeter security teams -- of which I was one of them -- it was like staring at a slow moving, never ending train wreck of comedic folly.

The mission as described was to find a downed C130, locate casualties, secure the scene, and evacuate the wounded. Pretty straightforward it sounds, but not so much in action. At least for us. After a short march we reached our designated stop point where our reconnaissance team was sent to evaluate the scene. After returning with the information of what they saw the team leaders and platoon leader collectively deliberated for a number of minutes before coming up with the simple plan of sending the two front security teams to secure the perimeter alone while everyone else just sat back and waited. That was it. No more plan than that. Not surprisingly it all started to fall apart when 5-10 minutes later we began to hear gunfire and explosions about a half mile down the trail where our forward security teams had so nobly previously wandered off to.

Not having any contingency plan for what to do in case of explosion we briefly fell back to the tried and true action of staring at each other in confusion for a few seconds before we all made the collective decision to simply get up and run as fast as we could towards the scene of the action. So off we ran, all sixteen of us in two rear security teams and two litter teams and all in various states of disarray, not entirely sure where exactly we were going or what we were to do when we got there.

We arrived to find a half erected security perimeter set up around a lightly smoking C130 and a few ramshackle cement houses all surrounded by the scrubby trees and dust which make up the majority of south Texas. Carrying only our plastic rifles, canteens, and the same Kevlar helmets and flack jackets that everyone else had, my rear security team passed by the column's litter team in an attempt to complete the half ass parameter that was already in place before they got there. This placed me immediately adjacent to the C130 and privy to all the action which was about to unfold.

The litter teams arrived shortly after we did to what was still a relatively unexciting scene of smoke, sound effects, and people lying around with rifles staring off into the trees pretending to provide cover. One litter team diverted off into a gully on the left to assist some wounded there while my column's litter team headed directly to the right to the downed C130 where, presumably, the bulk of the wounded would be waiting. This latter team, litter team 1, was composed of a motley crew of four: one young, fit, and tall male Army nurse; one young, fit, and tiny female Navy nurse; one older, overweight, and enthusiastic Army physician assistant (PA); and one very old, very huge, and very Colombian Army nurse. Together they approached the smoking aircraft in a disorganized run, but whereas most the team slowed on approach, the PA ran full steam ahead into the back of the craft GI Joe style yelling a heroic, "I'll save you!" This was followed by a loud bang from deep inside the dark aircraft and all went silent.

"I've been shot!"

"Who is it? Where are you?"

"It's me! I've been shot in the chest!"

"How do we know it's you? .... Who won the 2007 Super Bowl?"

"How the fuck would I know! Come get me out of here!"

So went the back and forth between the faceless voice in the front of the blackened plane and the skeptical litter team waiting reluctantly outside the ramp doors of the back of the craft. Finally, either sufficiently persuaded or for lack of anything they could think of better to do, they decided to go in after him.

*BOOM!*

Immediately after their collective decision to enter the C130 the two hundred pound Colombian Army nurse stepped on a land mind placed right outside the plane and was out of action. Within just a few minutes litter team one was down from four medics to two.

"Ahhh! My leg! I lost my leg!" screamed the Colombian clearly enjoying the opportunity to pretend to be wounded as he rolled around the loading ramp of the airplane. His comrades attended to him and began applying tourniquets as taught while he continued to thrash about as imaginary blood loss led to imaginary hysteria. Their task was not made any easier by an impressive size differential as the remaining medics had over a one foot and hundred pound size differential between them. The platoon leader who had been supervising attempted to instruct them towards cover while simultaneously seeking assistance from litter team two who had just recently secured their wounded in the gully. He had mixed results.

Treated but still lying exposed outside the airplane, the bulging Colombian Army nurse was left to wait while the two man litter team one went back into the smoking darkness to retrieve the rest of the injured. The explosions around the landing zone had mostly tapered off by this point, but the sporadic gunfire and incessant yelling from the TIs who offered mostly unproductive or entirely terrible advice continued. The platoon leader continued to shout instructions most of which were either unheard or unheaded. Around this time litter team two came to assist. Not sure of what was going on exactly and hesistant to act they loitered outside the plane.

*Crack!* *Crack!* *Crack!*

Fed up with the chaos and clear lack of command and control, the TIs decided to add to the situation by having one of the newly arrived litter team's legs shot out. Counting the PA still in the front of the plane, the Army nurse bandaged and bleeding outside the plane, and three more disfigured mannequins in the plane itself there were now more wounded than medics. What order there had been completely fell apart as the medics attempted to carry, drag, and pull whatever wounded they could to any semblance of cover available. This was made all the more difficult by the fact that the inside of the cargo jet had been heavily coated with fake blood for the fake bodies. When the medics emerged they would as often as not be covered in as much or more blood than the mannequins themselves, and frequent stops were necessary to reposition and regrip the slippery wounded. The inability to effectively move the heavily lubricated mannequins eventually earned them the term of endearment, "greasy Ken dolls." One more land mine went off, and the mission was over.

The post-mission debriefing was an unhappy and frustrated attempt to explain what exactly went wrong -- essentially everything it turned out -- and what could have been done better -- maybe not step on so many land mines? It was an excellent example of how not to execute a rescue mission which was not too much of a surprise considering none of us had ever done anything at all like it before. I'm not entirely sure if I was supposed to leave my post on security to assist with the moving of bodies, but it likely would have just led to my legs getting blown off. In either case it was an amusing story since in the end we all kept all of our limbs. "I'll save you!" became the catch phrase for our platoon and the battle cry for all further field training during the course.Thankfully no further mannequins had to lose their lives in rest of training.

Sing A Song Of Celeberation

Glory, glory, hallelujah! I have graduated residency and will soon by shedding off the chains of oppression. Loosening the bindings which have held me down. And getting the heck out of these dry barren, South Texan lands as swiftly as possible. (To be fair San Antonio *does* have four seasons: early summer, summer, late summer, and not summer.) The indentured servitude is coming to a close. Truthfully I have one more week of medicine consults till I am truly free, but I plan to defer all medical management questions to my consult monkey who I have trained in the use of both Essentris and the red pocket medicine book. My only regret is that I will not be able to see the old hospital pancaked through controlled explosions, and my one great wish for the future is to see via video feed the old hospital pancaked through controlled explosions. People tell me New Hampshire is going to be cold and unbelievably snowy, but people don't know that for the seven years I've prayed for cold and unbelievably snowy. I'd rather get sweaty shoveling snow off my car than simply because I am sitting inside of it.

Seven more days of work. However many days of military out-processing. A day or two of packing. And freedom!

One Million Tiny Fireworks

Developmentally it's been said we doctors are a little slow. Life's milestones are delayed. We marry later, start families later, buy houses later, and start wearing our pants above our belly buttons all a little bit later. The continuous cycling of school and training, long work hours, and general social isolation all serve to make us a little retarded maturationally* speaking. Thus whereas most thirty year olds are living upstanding lives as industrious citizens by generally shirking all responsibility we are avoiding responsibility altogether by garnering ever greater levels of debt and inflated senses of self-worth. I have just gotten through my teenage years myself, thank you very much, and am confident that hanging out late all night in college is totally going to rule.**

Physically, however, the opposite is true. We old. Nothing brings about an early bed time better than incessant call. Our backs are stooped, we have no idea what day it is, and sometimes I find myself gumming my food even though I know I still have a full complement of teeth. This is never more evident than on New Year's Eve every December. Last year we spent a subdued evening watching the ball drop in New York at 11:00 followed by bed, and this year we spent a subdued evening watching the ball drop in New York at 11:00 followed by bed. We even had a mashed desert (banana custard and Nilla wafers) and a lively game of Bananagrams. Paul fell asleep on the couch at like 09:30 and the Yorkies refused to wear their party hats. Sometimes I don't know what to make of all this medicine business. Thankfully in a few years all I will remember is how young Ryan Seacrest used to look. Unfortunately I'll probably also forget my complete domination of Bananagrams.


Rapidly advancing senility aside, the real reason I want to write? Fireworks. Given the opportunity to return to my apartment at 11:30 I was once again able to witness the cities fireworks from the comfort of my dorm room. Although the video is unfortunately not entirely clear -- or steady, damn you Parkinson's -- there was exploding color and fire from horizon to horizon. Near 180 degrees of my own personal fireworks sampler.

Happy New Years to all my family and friends at the VFW!

*Yes, this is a word. No, don't look it up.

**Totally.

Beware Greeks Bearing Gifts

The Air Force giveth and the Air Force taketh away. All for national security reasons no doubt.

Recently I was given the “opportunity” to “be recognized” for all my “hard work” researching by working harder in order to summarize succinctly all said research on a not very conveniently sized laminated poster. This poster would then be displayed briefly in a room somewhere for people to pass by with indifference. For those not so easily persuaded, the best poster presented would earn the presenter a trip to Toronto to the national American College of Physicians (ACP) conference to take place in the spring. Being the eager, young resident that I was I presented my research like a sucker.

And I won. I won the research poster competition, and so qualified for the national ACP conference and, more importantly, a few days off work in order to attend. Or so I thought. It turns out I won nothing of the sort. Unbeknownst to the majority of us it seems there is a clause that if there are heaven forbid too many winners from our program only the power point research presenters actually really “wins.” Truly we were all winners, yes, but the winner that got the prize was not me. In all fairness I only competed against other Air Force medicine programs and so had a roughly thirty-three percent chance of winning just by showing up and affixing my name and a doodle to a 3x5 card – which in restrospect is what I should have done – but I was not too happy. As consolation prize I was given a plaque, a hardy congratulations, and an offer to return to work promptly to resume my prior duties. Those duties being on call. I would have liked going to Toronto and I would have liked not thinking maybe something nice could happen for my efforts, but Canada’s full of lumberjacks and grizzly bears I hear and nothing builds character like profound disappointment so perhaps it's all for the best.

Meanwhile the research train continues. Where else will it take me? I can only wait and dread.

Internal Medicine: After Dark

I just finished Night Float. It was crap. It turns out taking care of people with the lights out -- though much like taking care of people with the lights on -- is much less rewarding. I should have seen this coming considering the omens. Within the first five minutes of the first shift my intern lost an eye to the tarp covering the scrub stacks. He was only briefly incapacitated and was left only with a small bruise on his eyeball, but for a short moment I was torn between resuscitation and calling to find his back up.

Anyways, Night Float. Six times the number of supervisors with none of the actual supervision. Plus medicine consults, plus 72-hour consults, plus out of hospital transfers, plus morning report, plus an endless cycle of freetriplescore.com commercials on late night TV. Add to all those new responsibilities a generous supply of next day second guessing and general orneriness from the primary teams, and myeh. Truthfully, I would of rather been kicked in the junk. Now we'd have to haggle over the details, but nevertheless, do it again, kick me in the junk.

The hours themselves weren't that bad mind you; I actually slept rather well. Similarly not knowing what meal to eat at any particular time of day was disorienting but three breakfasts in a row never hurt anyone. My interns were both by and large good, solid citizens, and work load wise we truthfully got off relatively light. It was just the nature of the job, of being subject to a multitude of divergent interests leading to an inability to sufficiently satisfy any which made Night Float a lonely, thankless task. I suppose it developed character, but only if paranoia is a character trait.

It's done and over now, though. May we never do it again.

Exit 25

This past month I earned my Geriatrician Merit Badge. In order to do so I had to start five campfires, diagnose ten cases of dementia, and administer twenty-five Exit 25 interviews. Thankfully the second and third tasks are related as it turns out there is no better way to diagnose dementia then to disorient the elderly and there is no better way to disorient the elderly than the Exit 25 exam.

Although the most recognized and often feared aspects of dementia tend to circle around the increasingly noticeable memory loss that slowly penetrates the minds of the afflicted, this is not the truly incapacitating aspect of dementia and the scare is only superficial. Memory loss makes life inconvenient and tends to sap away from us much of what makes us unique individuals, but it by itself does not lead to the helplessness commonly seen in demented patients. If you or I are forgetful we simplify tasks, standardize routines, write down lists and so on. There are a variety of ways to compensate and people are adaptive animals if nothing else. What truly makes dementia a terrible disease is its effects on executive function: our ability to plan and act. Without this there is no ability to adapt and, as the disease progresses, there is no ability to lead a normal life. Young children often have wonderful memories, it's the poorly developed frontal lobes which make them act as young, dependent children. And so that's why the Exit 25 interview was developed.

The Exit 25 is a series of twenty-five questions designed in a variety of ways to primarily test a patient's executive function and cognition. And it does this -- it seems -- primarily by disorienting and making as uncomfortable as possible the target of the interview. Although some parts are fairly standard consisting of the "remember these 3 objects" and "repeat these phrases," many are not. They range from tests of primitive reflexes and learned behavior by pushing and prodding on the patients' hands and arms in a variety of manners (and also tapping on their lips) while continuously telling them to "just relax", to asking them to stick out their tongue and say "ahh" for an uncomfortably long period of time, to a series of complex hand maneuvers that I still have not quite completely mastered myself. The best parts, however, are the ones I can rarely do without laughing.

The first is simple enough. Complete part 19 and then suddenly and without warning clap closely and loudly by the patient. If they do nothing but eye you curiously then they're in the clear. If they look about or motion uncertainly that's one point on the dementia scale. And if they clap back at you, a phenomenon called echopraxia, then it may be time to take the credit cards and car keys.

In a similar vein, the best portion of the test also consists of an abrupt, awkward transition from regular questioning. Part 10 is followed by a three second silent stare into the eyes of the interviewee followed by a polite and matter of fact "thank you." If the patient responds with a questions like, for example, "what the hell are you doing?" then they're good. If they again get anxious and flustered that's one point against them. And if they say, "you're welcome," well it may be time for a death panel consultation. My favorite response to date has been a panicked, "is this part of the test?! Is this part of the test?!" with simultaneous darting of the eyes to every part of the room.

In all seriousness the Exit 25 interview seems to be a consistently effective tool for screening and monitoring dementia, and will likely be an increasingly important one as it is more extensively used. Unfortunately I always feel bad doing it on my patients. It also takes a good twenty minutes to complete the whole bloody thing. Considering the main measure seems to be confusion and disorder, I almost feel as if yelling and shaking a gnarled stick at the elderly for a minute could have much the same sensitivity and specificity at a fraction of the cost in time. It's a shame I won't be going into geriatrics; I could have revolutionized the practice.

The best part of geriatrics was not terrorizing the elderly; however, it was the absence of call and two day weekends. Beautiful. And the worst part, conversely, wasn't trying to then persuade demented people that they were in fact demented, but rather the senior citizen two handed handshake I now find habitual. For whatever reason I found myself clasping with both hands the single hand of patient and/or accompanying family member in a gratuitous gesture of friendship. They seemed to appreciate it well enough, but some of my colleagues not so much. Men weren't meant to double hand clasp the hands of other men, and many a muffled look of befuddlement has been exchanged between myself and another as a result. It is either a sign of my great empathy or my folie à deux that I have become more like the elderly in treating them. Or perhaps it's just two more points on the dementia scale.

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.

The Great Pee Pee Mystery

Today, from roughly 1100 to 1700, I waited for an old man to pee so that I may take it and look at it under a microscope. Around 1715 I was given word that the long awaited urination had taken place. Briefly taking care of other urgent matters, I attended to my wee sometime around 1745 only to find it was nowhere to be found. Some masked stranger had run off with my urine. I asked the nurse, she didn't know. I asked the patient, he said "a doc" took it. I asked my interns, they were clueless. Somebody, for whatever clearly no good reason, had absconded with my wiz. I was upset. Although few will every appreciate this, there are few things more frustrating then waiting an entire day for urine only to have it disappear. Nevertheless it seems to be the running average for Williford Hall these days. Most labs get sucked up by gremlins in the vacuum tubes, most daily radiographs become every other day radiographs by the x-ray tech fairy, and half of our electrolyte panels seem as if the masked stranger himself is urinating in them yielding the wildest most ridiculous and inaccurate of results. Wilford Hall, you're too much for me. I don't know what to do with you.

Someone will pay dearly for the pee, though. Someday I will have my revenge.

Befuddlement

It was the best of times. It was the worst of times.

Or so I am frequently told.

Frankly, I don't find the times very enjoyable. In all honesty, though, I have no idea how to interpret them. These times apparently be confusing.

Relatively speaking us Air Force residents have got it easy. Compared to the internal medicine residencies of yesterday where interns and residents were shackled to their wards, forced to work while sleeping, and generally treated like so much chattel, we live lives of luxury with slashed work hours, broken chains, and alleviated patient burdens. Everyone always says it was harder back in the day -- and I am inclined to believe them -- nevertheless I am also inclined to believe that back in the day there were infrequent CT scans, no MRIs, only a handful of blood tests, and a pharmacy consisting mostly of a few penicillins, ergotamine, and phenobarbital. Twenty patients ain't so bad when all you can do is lay on hands and hope for the best.

Beyond that we've got it easy in other ways too. Compared to many civilian programs we work less, see fewer patients, are paid better, and likely are showed more appreciation by our patients. And compared to the hobos living immediately outside my apartment at least I have more to come home to than cheap booze and some invisible pets.

In absolute terms, however, residency is so much balderdash. We still work harder, longer, and with less perks and less confidence than the vast majority of Americans. Our job is in its very design constructed to make us feel continuously ill prepared so as to constantly compel us to learn. And through a legacy of estrangement many who teach and guide us have no great sympathy for our lot.

So how am I supposed to feel? Frustrated that it's not better? Happy that it's not worse? Thankful that I get to train for the unique career of my choosing or upset that all I do is train for the unique career of my choosing? I am undoubtedly incomparably blessed, but this particular blessing comes with an odd trial before the spoils. I have no means of measure and so am constantly wavering between emotions; I find myself muttering under my breath perhaps more than is healthy, and am thinking of joining the hobos.

Perhaps they'll let me take care of the invisible cat.

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!

A Labor of Love

I have been working 80 hour weeks for the past five weeks. I have three left to go. I do not enjoy it much. I leave to work with it dark outside and return to work with it dark outside. In these harsh and trying times I like to think of a block back at BAMC when my co-intern stepped in to visit a patient of his.

The woman, elderly, foreign born, and a bit demented, had just had a nasogastric tube inserted through her nose to relieve the pressure building up in her gastrointestinal track. Being so demented she did not terribly appreciate this.

Upon entering the room to see how the procedure had faired she, from her curled up position in bed, waved her grizzled hand and said in her thick East European accent, "Traitor."

"You'll pay for this."

The joys of patient care.

Today a family in clinic gave me a pack of gum. It was pretty good.

Ahh... for the good ol' days....

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.

Fair Weather Ahead

There are certain truths concerning medicine that are kept from the general lay public for the public health benefit. Mostly their peace of mind -- not so much their actual morbidity and mortality. One of these truths is that July is the best time to be killed by your doctor. Ninety-nine percent of residencies begin in July and all the fresh new interns -- most of whom know less than they did than as even fresher third year medical students -- combined with fresh new senior residents -- who were themselves only a year ago fresh new interns -- mean that the chances of you getting worse from your hospital stay are almost as good as you getting better. The same hand extended with an awkward smile to greet you on the gurney may be the same hand making the sign of the cross while pronouncing your time of death.* I imagine these statements won't actually hold up to statistical analysis thanks to excellent supervision, but it's a medical truth! It is so.

Another medical truth is that there are some physicians that bring with them them the storm clouds of disease close in tow, and then there are some physicians who are bathed in a gentle light of health bringing peace, refuge, and pockets full of medicine wherever they go. Black clouds and white clouds. So far, after two calls, it seems I am a white cloud. Not through any effort on my own part mind you; no one knows how the Gods decide the status of each physician. It is theorized that they either draw lots or simply look down from their collective ivory towers and name off the first few people they see, but whatever the means, once ordained it is unshakable. In my one and a half weeks of residency I have admitted three patients on two call nights and taken care of perhaps another three. This is less than what many teams see in a single call night. Sometimes I lay hands on patients and they get better, blow kisses at children so they'll stop crying, and wink at the elderly so as to resolve their dementia. None of this ever works of course as that's not how the black cloud/white cloud system operates, but I like to do it nevertheless.

And the last medical truth I will share with you all is that most medical truths are contradictory. Some may like to use the term "paradoxical," but, no, they're usually just contradictory. And as we residents are a superstitious lot it is likely that by mentioning my white cloud status just now I have successfully jinxed it. I am on call this Friday. I am expecting sixty patients.

*Actually I don't think most residents make the sign of the cross when pronouncing people dead. Except for maybe the Catholic ones.**

**Is this Catholic racist?

And Remember Kids

I have not officially begun my residency career, but I would like to lodge my first official complaint. With today's newer, softer physician training programs work hours have been slashed, antisocial personalities heavily medicated, and positive things said all around, but with such unbridled kindness and cheer has, as is so often the case, come also a little bit of insanity. Specifically, all the heartfelt behooving to "live a balanced, satisfying life" is ridiculous. I do not have any children, significant others, financial responsibilities, social commitments, or even a pet of any significant size, but even still I can confidently say that I certainly do not have much free time with my 80 hour work week to lead a life in harmony with my family, friends, and nature. The rest of the world seems to have enough trouble getting by on a 40 - 50 hour work week, and, given, though the average American may be in need of a few hour handicap to deal with some of the problems he gets himself in if the average American cannot live such a life with a 30 to 40 hour advantage are we to assume he is just lazy? I do not wish to create the impression that I think residency should be regulated to a 40 hour work week, and indeed in many ways sacrifice can at times in some ways make life stronger, but let's not play this silly mind game that living the good life as a resident is simply a decision that we make. We can make the best of what we got, but let's not pretend that what we got is anything fantastic. Residency is meant to be tough and our family, friends, spouses, and pets will feel neglected because they will be neglected. All the double think and smiling faces in the world ain't going to change that. So the next lecturer who tells me to take a quick nap after 30 hours of continuous work on call so that I don't somnolently drive my car off a bridge embankment and then in the same sentence tells me to take time out for the small things in life is getting a alphanumeric pager to the back of the head. You know, the big kind. With AA batteries. Grrr.

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.