Suck it, Emirates!

If I may be profane for a second.

Thank you.

Finally! After some six months of continuous effort, multiple phone calls, two parcels, and over ten emails I have, finally, received my reimbursement check from Emirates airlines for causing a missed flight and having to pay to reschedule! Finally! $100 for me! Generally I am all about fiscal responsibility -- maybe buy myself a nice US savings bond or invest in a mutual fund I'd say -- but, now, I think I may just spend it all on booze and loose women. Just to spite them. As much as a faceless, global corporation can be spited at least. (In all respect the company personnel were always very cordial and nice. Just slowly cordial. Very, very slowly cordial.)

So maybe I'll trick out my new bike. Maybe a horn? Gratuitous reflectors? Those rainbow colored click clack things you stick on the wheel spokes?

A Bit of a Cat Problem

I wade through cats when leaving the house towards work in the mornings. Cats waist high, fifty felines deep; it's a bit of a problem. Thanks to the generous daily donations of food and water by our next door neighbors the local tabby population is expanding rapidly and will likely soon blot out the sun. With cats in such tonnage also comes kitty waste, and that's also becoming something of a problem. For my roommate at least. Although I am not so fond of our not dog friends I do not terribly mind their presence all too much. Laura, on the other hand, seems to have a far more sensitive nose and far less patience. Generally speaking she's a fairly calm and collected person, but under the guidance of her parents who visited recently she has begun a war of attrition aimed at ending the scourge that is stupid, skittish, feral cats.

The solution, initially, consisted mostly of bleach. Lots of cleanser to cleanse the urine smell and burn the lungs of any animal lingering too long on the porch. Our front door briefly no longer smelled of tom cat tinkle but instead like a very heavily chlorinated pool. This was only the opening volley, however, in what was to be a bleach, moth ball, and ground black pepper triple offensive, and the very next day I arrived home from work to find a generous scattering of little white spheres throughout the front yard planters. It kind of looked like it had recently hailed had it hailed only quarter inch sized balls of ice, but the pungent smell of ammonia replaced the chlorinated pool smell making it obvious it was the moth balls. Is it working? I am not sure; I have been headed to work later the last few days and generally speaking the cats scatter to go about their cat business shortly after sunrise, but I believe the Gallos are stockpiling mustard gas just in case.

Unrelated to the current arms race, I took the USMLE Step 3 yesterday and the day before. That's all I got to say about that. If there's any secret police more feared than the HIPAA brown shirts its the Federation of State Medical Boards Stasi, and I fear I have already said to much.

Doubly unrelated, I bought myself a new mountain bike with my economic stimulus check. A 2008 Specialized Rockhopper! Yeah. Awesome. Basically it's a bike, and it's blue. The rest is all kind of muddled. There are apparently about 2100 different mountain bikes produced with varying ill-defined features, and I am pretty sure I purchased the Rockhopper mostly because I just subconsciously thought the name was outstanding. Anyways, consider the economy stimulated! I've done my part Mr. President!

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.

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?