Little Laura Goes to War

A short while ago my good friend and former roommate Laura got a letter instructing her to get her gear, she's going to war. Deployment time. Brass knuckles time. Whether it would be Afghanistan or Iraq was still to be determined, but a few things were clear: she would be the first of us to deploy and she'd need to find a way to strap more grenades to her chest. As it would turn out her deployment was not per the usual, however. When her deployment letter finally came instead of being tasked to a forward operating base or major theatre hospital in country hers read: you're going on vacation! Her six months of service to the nation would be an all-expense paid trip to Germany where she'd visit the Swiss Alps, lounge in Bavarian beer gardens, and take in culture and class at many a Baroque Austrian palace or concert hall. Sure she'd be caring for patients and war wounded at the medical center in Landstuhl, but as judged by the constant stream of Facebook photos since, she's mostly there to party.
 
Despite the fact that she had likely ruined deployments for all the rest of us for all the future I decided to pay Laura a pre-deployment this-may-be-the-last-time-I-see-you-alive visit. It was also secretly a visit to the Historic Triangle of Revolutionary America and an excuse to get a tricorne hat. The trip was successful on all accounts.

The trip was not without hardship; however, especially if you like to use the word "hardship" as a stand in for "never ending rain." The rain didn't start till after we set out on our twenty something mile bike ride, but once it started it never stopped coming. Quickly we were soaked, but still we rode on.

Whenever I insisted we stop and admire a local landmark Laura often insisted she wait under a tree. We then had a very wet lunch, and proceeded to have a very wet ride back after leaving behind very wet chairs and table clothes behind us.

We didn't stay in Yorktown or Old Williamsburg all too long, but there's always time for victory poses. Just like back in 1776.

Once all that was said and done we settled down to what really mattered. College football and puzzles.

Laura made this while slowly losing her mind -- smashing together decorated styrofoam is apparently more difficult than it looks. Coincidentally I was also losing my mind for an entirely different reason -- thank you Fighting Texas Aggies. We also saw a movie, had some food and drink, and then Laura went off to war. Went off to war a few weeks later after visiting other family and friends to be entirely accurate, but I'm pretty sure what prepared her most was my inspiring visit. My hat spurred her into a patriotic furor.

Code Sepsis

Hospitals got secrets. Where we buy our kidneys, where we hide our bodies, what that drug that starts with an "x" and sounds like "manex" is. It's what all the locked doors and privacy's about. Not personal protection, but cover for a massive, secret effort by the health insurance industry and World Health Organization to put thimerosal in all the tap water and autism in all your children. We're up to something, and let me tell you: it's gonna be big.

One secret I can share without fear of a propofol coma, however, is the color code system which keeps hospital staff informed of impending disasters while simultaneously allowing all our naive and overly trusting patients to continue wandering about the hospital premises. Maybe they'll wander into a fire, maybe an armed assailant, maybe a chemical spill, or maybe all of the above. It's for us to know and everyone else to eventually find out. In this system each conceived of disaster is assigned a color which is then relayed over the hospital intercom. The most common code is the "code blue" for cardiac arrest -- or as it often is at our facility, old man down in the parking lot. Additionally, however, there are "code pinks" for child abduction, "code oranges" for chemical spills, "code greens" for aggressive, angry person, and, most recently added, "code whites" for aggressive, angry person who is now shooting a gun. Many of these codes are adopted across the country with some variation, but there is one that is relatively unique to San Antonio: code sepsis.

"Code sepsis" is the call for the medical intensive care unit (MICU) team to come and evaluate a septic (severe infection) patient for immediate admission to the MICU. Practically speaking, however, it's the call for everyone in the ER to don their crazy hats and go completely out of their minds. Twenty people surround what need only be a 3 or 4 man intervention while central lines and endotracheal tubes fly about in a mad effort to place the patient on minimal ventilator settings and a random dose of dopamine vasopressor. Sometimes the patient will get antibiotics during this time, sometimes a nurse ends up with a femoral catheter in groin. Once this is concluded, typically shortly after the MICU team has arrived, the crowds disperse in a flurry of triumph and indifference while the staff begin the hard work of incessantly pressuring the MICU team to admit the patient to the unit as quickly as possible lest the chupacabra get them. Eventually the orders get in and the insanity returns to normal levels, but not before there is one last self-congratulatory high five.

So it is with my career currently. Somewhere in mid-December the Air Force yelled, "code sepsis!" and all sorts of rip up your bed sheets, fling your poo craziness has ensued. In the course of completing my residency and determining my future station in life I've worked at three different hospitals, flown to two separate fellowship interviews after sending out dozens of separate emails and making dozens of different phone calls, underwent ATLS certification and a week of military field training, had some vacation, had my computer die, got a shot, got an HIV test, got some lunch, filled out an unholy amount of paperwork only to be rewarded with even more illogical sums of paperwork, created and given a lecture, attended a mid-year evaluation meeting, had my already completed research project randomly chosen for quality control review and then had that review canceled, planned for an upcoming medical readiness training exercise (MEDRETE) in the Dominican Republic, and been booted from a base reassignment process entirely without my knowledge. I have not at any given moment been entirely sure of where I am or what time of day it is, nor do I even really know where this all is heading, but I am confident that, in the end, the Air Force will totally be throwing the high fives all around. They'll have done their job of sticking me somewhere, and I will have been successfully stuck somewhere. Good job guys, the chupacabra didn't get me.

Oh Canada

Canada!

We have been estranged too long.

I am coming for you!

After twenty-seven long years of living in ignorance of my northern neighbor, the sum of my knowledge stemming from a few Rocky and Bullwinkle cartoons, a Five Iron Frenzy song, and some pictures of what was likely Antarctica, it is time for change. Real change. Powerful change. Barack Obama-style change -- though with less ambiguity and non-productivity. It's settled! I am going to Canada, and in the national spirit I will hug a Canadian. Which I can only assume is an eskimo.

In anticipation of this warming in relations, I have heavily studied the recent 2010 Vancouver Olympics. Although it took me two weeks of additional TiVo watching to get through it all, or most all of it save yet another women's biathalon with fatigued Norwegians drooling all over their rifles, I have learned that some Canadians are good at sports and NBC news personalities seem to enjoy mounting and riding moose. Or mooses. Or meese. I think this is sufficient information to bridge the cultural divide.

I have the USAF to thanks for my pending travels. After further consideration, and a second round of acceptance from the ACP, they have agreed to pay my way to Toronto for the the National ACP Medical Conference where I will present my research and, I guess, do some serious conferencing. Having never been to one of these events before I am not sure what to expect. Boring lectures? Boring lectures by distinguished guests? Internal medicine physician dance party?

This brings me to my last question, though, what to do in Toronto? I hear they have a tower. And.... the Blue Jays? Perhaps I will get myself some milk in a bag. Or stir up the Quebecois.

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.

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.

It Was a Dark and Stormy Night

It has been a number of months since San Antonio has had a good rain. Yesterday, and today, we finally had one. And then my car battery died.

It is actually not quite the coincidence that it sounds. It turns out that I regularly am in the habit of not turning my lights off when I park my truck when it's raining outside yet still light out. This thing seems to happen about once a year. Nevertheless, usually it is not 12:00 midnight and usually it is not 40 something degrees out and usually I am not stuck on an Air Force base after having being working all evening. Thankfully, after the base's security forces refused to jump me (they apparently have a strict no-helpfulness policy), my dear, good, gracious, reliable friend Beau who happened to be working an overnight shift was there to help me restart my car. It took about 30 minutes to get it all done seeing as the cables were never quite long enough and we had to push my truck out of its parking spot to get closer, but we did it. We were both soaked, Beau was possibly hypothermic, and I had lost faith in my country. (Seriously base police, you cannot give me a jump in the middle of the night in the middle of a storm? Seriously?) On the relatively slow drive home, sometimes it seems like San Antonio was designed specifically with the purpose of flooding in mind, I was treated to one more bit of excitement as getting off the highway I, and the car slightly adjacent of me, disappeared into a sea of water that effectively submerged our vehicles and made me exclaim, "Oh, shi-" right as the cameras cut away. Perhaps it's good that it doesn't rain here too much.

But internship progresses. I am in the ER now. Because last week I was doing evening shifts from 1500 to 2300 and there are not always patients at the ER from 1500 to 2300 thereby leading to my early release some days I have not had a consistent schedule for most of it. I am wholly disoriented. Every day feels like Sunday and every hour like roughly 9 pm. I never know quite what I should be eating, when I should be eating it, and if I am eating enough or too much in a day (not that I likely could eat too much though.) I'd guess the time right now but I'm as likely to be 5 hours off as 1, and it's not like I would know what to do with that information anyway. At least I still know who I am, that I live in San Antonio, and that Ronald Reagan is president.

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.

Gone a Soldiering

After a two year long hiatus I have once again incorrectly donned my BDUs and headed off for a brief active duty tour with the United States Air Force. Zoom!

Wright Patterson AFB in Dayton, Ohio, is an immense installation occupying a large portion of the surrounding area. If you look at it on a map you may think, "dang, that's a big base." Well, not quite. The area encased by acres of razor wire and blocked off gates is indeed quite large, but it turns out its mostly well watered putting greens and hazardous sand traps. Aside from the hospital it seems that much of the base is offices and golf courses. I can't complain, though, the less personnel there the less likely it is anyone will notice I've almost completely forgotten what I'm doing. And they have the most unbelievable wooden playground I have ever seen. Some day I will make a pilgrimage with my own kids here; it will be glorious.

One of the greatest truths I feel about the military is that it does the best with what it's got. Sometimes this is quite a lot, and sometimes it's not much. In this modern era of ours medical doctors are frequently somewhat hard to come by generally speaking, and this shortage is particularly acute for the armed forces. Few doctors want to undergo further teaching, testing, and training all for a bit less money and with little say on where they get to live only to be yelled at in the end that they're doing it wrong. As a result the military frequently has to go out of its way to limit the extra burden it places on its new recruits and so sends them off to things like Commissioned Officer Training (COT) hoping in one month to teach them everything they need to know about being in the military. The end result is perhaps a few more doctors, but they're all doctors that march crooked and salute funny.

And so with this in mind I returned for another month of the airman's life with a significant degree of anxiety. I was reluctant to leave my hotel room -- more formally known as the Visiting Officers Quarters -- for fear that I was doing something wrong and when I did do so I made sure I moved as efficiently and discretely as possible so as to avoid attracting any attention to myself. Thankfully the hospital, as it is itself composed of mostly high ranking COT medical graduates, was particularly laid back, but even there I was not free. On the first day I got ten demerits for having with me the wrong colored backpack and a week or so later I received a couple more for wearing my hospital ID attached to my BDUs outside the hospital's doors. Aside from these few infractions, however, I was mostly safe and within a few days was once again at ease. I did have one last incident of note, though, involving twice running into the same foreign military officer and not knowing what to do either time. Do you salute? Does he salute? What rank is he anyway? Are those stars? He can't be a general; looks too unimportant to be a general. Why do all these foreign uniforms have so much flare on them? Is he staring at me? Oh god, now what? Stare back? He's not moving. Keep staring. Stare harder. Now look away. And... pass. I still have no idea what exactly I was supposed to do, but after awhile I've learned you get comfortable with that feeling.

Anyways, the Air Force business aside, the residency program was, I felt, not so bad. The hospitals looked fairly nice, free food at the awesome Miami Valley cafeteria, much more attractive nurses than down in San Antonio. What was disturbing on the other hand was the people involved. Although I don't think any of the attendings were bad people per se, many of them seemed to feel obligated to have an uncomfortable, unpleasant working relationship with their residents and interns. The residents seem to have gotten used to this. The interns seem to have become depressed. I honestly felt an air of melancholy while I was in the hospital. The place just seemed unhappy.

My interviews were mostly a huge waste of time. I suppose many of the staff need to get at least a rough idea of my personality, but that's all they got as few questions were asked and each session was mostly a brief conversation and a good series of hand shakes. One of them didn't even ask me any questions aside from how I was liking my rotation. What bothered me, however, was not the general silliness of the interviews with the Air Force folk, but my one interview at Miami Valley. The woman knew nothing about me aside from the limited information on my personal statement which was short and vague in compliance with the military's requested word limit, and yet she chose to ask me, "are you the first doctor in your family?" "What makes for a good attending?" "What do you like about our program?" What do I like about your program?! Uhh, pass? I don't like your program. I wouldn't be applying for your program if I was not limited to it and two others one of which was recently destroyed by a hurricane. How about your cafeteria, that seems pretty nice. Do you actually want to know anything about me? And so our interview went. Thankfully the other fourth year HPSP student I interviewed with felt much the same. If I'm gonna be arrogant and presumptuous at least I can be arrogant and presumptuous with friends.

My interviews aside the rest of my stay was mostly joyous. The Uniformed Services University of the Health Sciences (USUHS - pronounced "yoo-shuss") students were all for the most part friendly and cordial. Went went about town most weekends, listened into the Sheryl Crow concert (who knew the woman had so many famous songs?), and even visited the much talked about Oregon District (in Ohio Oregon is apparently pronounced "Ore-eh-gone") which consisted mostly of scarcely occupied bars and adult erotica stores. I also made it to the USAF Museum; a surprisingly enjoyable and interesting experience. Also a ridiculously difficult place to take pictures in which, combined with my naturally poor picture taking abilities, produced some pretty crappy photos. Ohio, as a whole, I feel is not a bad place to live. I wouldn't mind coming back the residency program notwithstanding. It's definitely different than San Antonio, though the obesity's the same, but in many ways it's an enjoyable different. We'll see what the Air Force says.

As a final thought, it seemed most streets on base were not named with historical figures, important geographical landmarks, or really anything the least be significant or inspiring. Instead they were things like Evergreen Wood and Doe Brook. If ever tasked with naming the roads on the base I end up at I'm definitely going to be living on Exploding Freedom Avenue.

Pictures!

Oh, and it turns out I do like Infectious Disease after all.