My blog for the next six weeks

After a very snowy week in Camas, I am again sitting in an aiport (PDX) for the nth (I'm too lazy to count) time this year, waiting to go off on my next adventure. For those of you who don't remember, I am going to be spending four weeks in Papua New Guinea on a Global Health elective, learning about tropical medicine and basically working on not getting dengue fever (I have medicine for malaria and am vaccinated against just about everything else, so that's what I'm going with).

As part of my rotation, I will be keeping a blog with INMED, the organization that is taking me to PNG. Obviously, as I will be in the bush of a strange foreign country, internet access will be patchy at best, and I will not be keeping two blogs. So, here's my link to where you can see what I'm up to until I return:

inmedblogs.us/elisabethhesse

Enjoy, and I'll talk to you soon!

Match results!

The military match results came in this morning at 0600 EST. I have, obviously, been looking forward to this moment for months, if not years. Here it is:

Walter Reed Army Institute of Research preventive and occupational medicine residency class of 2013

Yay! That was my first choice and I'm quite thrilled with the results. Tonight is our post-match Military Medicine Interest Group meeting, so I'll find out how my military classmates did and where they'll be going.

Anyway, here's my schedule for the next four years:

July 2009-June 2010: transition year internship at Walter Reed Army Medical Center
July 2010-June 2011: Master's of Tropical Medicine and Hygiene (or Master's of Public Health) at the Uniformed Services University of Health Sciences (or, if I get an MPH, at Johns Hopkins University)
July 2011-June 2012: Preventive Medicine practicum year at Walter Reed Army Institute of Research
July 2012-June 2013: Occupational Medicine practicum year at the USUHS

I don't know how they expect me to do work today. I'm too excited!

Pain medication contracts

One of the things about worker's comp patients is that most of them have chronic pain that has to be treated with narcotics (think Dr. House and his Vicodin addiction). Obviously, nobody likes to just give out narcotics (well, unless you're on House, in which case, everyone gives it out like candy). There are a lot of legal and ethical issues involved in prescribing narcotics, so the doctors try not to do it without thought.

So at the OSU Occupational Medicine clinics, the patients must sign pain medication contracts once a year before they can be prescribed narcotics. The contract is a couple of pages long, and I won't bore you with all the details, but some of the points they have are that the patient must agree that they will only get narcotics from the occupational medicine doctors (ie, they can't go to the ER for pain meds), that they will take them only as prescribed, that they will agree to random drug screens (both to make sure they are taking their medications and to make sure they aren't taking anything else), and that if they break any of the rules, they won't get any more narcotics.

Well, we had a patient yesterday (Friday) who Dr. Wynd is trying to wean off Percocet. She had been prescribed 1 pill four times a day, and a few months ago, Dr. Wynd decreased it to 1 pill three times a day. So, to make what was actually a really long and convoluted story short, she was still taking 1 pill four times a day, which Dr. Wynd confirmed by counting the remaining pills. So, she wasn't taking it as prescribed, and that means no more Percocet. Dr. Wynd prescribed Ultram instead (a non-narcotic pain med) and pretty much said, you knew the rules and you chose to break them.

I'm not saying the patient didn't have pain; she had quite a lot of pain, both leading to and resulting from a knee replacement surgery and three back surgeries. However, pain or not, rules are rules, and she knew them and broke them. If she was having as much pain as she said she was having (leading to the increased intake of her meds), she should have called for an earlier appointment to ask for another prescription, instead of just changing the dosage on her own. That way, she wouldn't have been in violation of her contract.

Unlike on TV, doctors are aware that narcotics can be addictive. They are also aware that they are sometimes necessary. The tricky part is getting things down so the pain can be treated without causing further harm to the patient.

OSUMC Clinical Epidemiology

Today I spent the day with the infection control team at OSU. The day started fairly early, as we had to review all the culture results for the entire hospital (it's a 1000 bed hospital; fortunately, not everyone gets cultures). These have to be monitored for a few reasons: 1) If anything wildly contagious/dangerous (TB, meningitis, etc) is cultured, the epidemiologists have to begin contract tracing and making sure everyone who has had contact with the sick patient gets proper treatment. 2) Infections, especially hospital-acquired infections, must be reported, according to the Joint Commission (the group that accredits hospitals). 3) Following bacteria and what they are resistant to allows for better antibiotic prescribing practices in the hospital.

After going through the culture results, I went on rounds with the infection control agent of the Ross Heart Hospital (one of the four hospitals that makes up OSUMC). It was rather interesting; many of the things we were looking out for were things I had never considered, such as the exact location of sinks and soap dispensers, making sure all procedure rooms have sterile areas, and checking for dust that housekeeping has missed. By the end of rounds, we had put in two work orders, one for a shelf in a procedure room and one for a sink. We also discussed how infection control personnel can be involved in hospital design, to make sure each room is properly set up for a given purpose.

This particular infection control nurse has been working with the cardiothoracic surgeons on reducing the infections associated with ventricular assist devices (VAD, or for any Grey's Anatomy fans, LVAD). Fortunately, one was being removed and replaced in one of the ORs today, so we went in so she could point out all the infection control changes that have been made, which have resulted in OSU having the lowest infection rates for VADs in the world.

After lunch was the Infection Control Committee meeting, which included reports on the hospital acquired infections and what is being done to reduce those numbers. After that, I went on rounds with the ICU infection control agent. We discussed infection rates and monitoring in the neonatal, medical, and surgical ICUs, and then went on rounds to those areas. All I have to say about that is NICU babies are scary. One pound is pretty small for a human being.

Anyway, at the end of the day, I feel that I learned a lot about epidemiology and how it applies in a hospital setting. It was more of a preventive medicine than occupational medicine day, but that's okay with me.

Dr. Wynd's Back Pain Clinic

No, there was no back pain clinic, just more occupational medicine, but for some reason, every since one of Dr. Wynd's patients this morning had complaints of back pain. It got a bit monotonous, but I've gotten a lot of practice doing back exams.

Occupational medicine hasn't been treating me too poorly. Most days, I start around 8, and head home around 3. Dr. Schaub, the doctor I'm mostly working with, has been getting me in various clinics and sites, including both occupational medicine clinics at OSU (neither of which are at OSU), employee health at OSU, hospital epidemiology, and the Big Lots warehouse (he's the Big Lots employee physician). Many large companies, especially large companies with warehouses or factories, have staff physicians, often certified in occupational medicine. That's pretty much where the money is in this specialty (and it's good money, from what I hear). Government agencies also employee occupational medicine physicians--of the OSU physicians I have worked with, Dr. Rodway is a DOT physician, and Dr. Kearns goes to the Defense Supply Center Columbus and is also a FAA flight surgeon.

Anyway, that's pretty much all I do every day--go to clinic, see people who have been hurt at work, see how they're doing, figure out what we can do for them, and try to get it done. There's a lot of government red tape to go through, which makes me very glad that I'll be doing this in the Army and not in a civilian setting. The Army actually makes things simpler.

Worker's Comp

This month, I'm doing an occupational medicine elective. I wasn't sure what all that entailed until I met with Dr. Schaub, my preceptor, yesterday morning, and I'm still not completely sure, but here's what I've gathered thus far: most of my days will be working in one of two occupational medicine clinics in Columbus, and I'll also being spending half days doing hospital epidemiology at OSU, work-site inspections at major corporations in Columbus, and working with FAA flight surgeons. Thus far, I've done half a day in the occupational medicine clinic.

Occupational medicine clinics aren't primary care offices, and occupational medicine docs aren't primary care physicians. The only reason for the visit, and the only concern of the physician, is what was injured while the patient was at work. People on worker's comp have to see occupational medicine specialists on a regular basis, for continued evaluation of their injuries, to determine if they are fit to return to work (and what duties they can do there), and to coordinate care with other specialists. That is all the doc is worried about--no lecturing the patient about not taking their blood pressure medicine or checking their blood sugar.

So before I began my shift yesterday, I was given the half-hour lecture about worker's comp and how it works. Dr. Schaub explained by explaining how things were before worker's comp: if you were injured at work, the only way you could get money for your medical bills and lost wages was to go through the tort system, and to do that you had a hire a lawyer (obviously), and had to prove you were injured at work (not so difficult if you came to work with ten fingers and left with nine, but more iffy if you developed lung disease after working in a coal mine for thirty years). There was also the assumption of risk, meaning that there were certain risks at every job, and if the employer told you about the risks, you accepted that you were okay with them when you started working there, and thus, any injury as a result was not the employer's fault.

Now, with worker's comp, it's completely non-tort--in fact, you can't sue your employer if you're injured at work. No lawyers are involved, and all that you have to indicate is that there is a "reasonable medical probability" that work contributed to the injury, so now that covers things like Black Lung Disease from coal mines, carpal tunnel syndrome in secretaries, etc. There is no assumption of risk; if the job-site isn't safe, it's now in the employer's best interest to make it so, in order to keep people from getting injured.

The biggest misconception about worker's comp is that it's permanent disability; it isn't. That's social security. Worker's comp only pays temporary total disability, and if you can't get back to a job before that expires, you're done. Notice I said a job, not your job--employers may have you come back doing something that won't aggravate the injury, and if you can't handle that, you may need to get a new job. One nice thing about this is if it becomes obvious that you can't go back to what you were doing, you could be enrolled in vocational rehabilitation, which helps you find/train for a new job that you can do with your injuries.

So yesterday we saw a variety of patients, from a legal aide with carpal tunnel (we had a laugh together about that one, as we both had our wrist braces on), to a TSA agent recovering from a broken knee after a fall while he was searching a passenger, to a woman who was going to have to enter vocational rehab, as she had been making no progress gaining strength in her arm after a fall on her shoulder a year ago. Many of these patients were eager to get back to work doing something; in fact, the legal aide was still doing a lot of typing on a daily basis.

I guess I never really considered how a relatively minor injury could sideline someone in certain positions. For example, we cleared the TSA agent for full-duty yesterday, but he still could not kneel on his right knee without pain, which means that while he's searching passengers, he'll have to remember to drop to his left knee, and while he's lifting luggage, he'll have to remember to support it with his left. We also had a correction's officer with a sprained thumb who couldn't go to work at all; even the most limited-duty jobs (ie, watching monitors) could conceivably require her to restrain a prisoner, and without grip strength of her hand, she couldn't grab someone and put them in handcuffs. Sometimes, it's all about putting the injury in perspective.

Happy Thanksgiving, and farewell to Tripler

As some of you know, I am now back in Ohio, having left Honolulu at 4:50 pm HST on Thanksgiving. Somewhere in the process, between the long flight and time zone changes, I lost an entire day. I'm still having a hard time believing it's Friday. I'm also having a hard time staying awake, so I apologize if this post doesn't make much sense (as tempted as I am to get sleep, I'm trying to go to bed at a reasonable Ohio hour to ward off jet lag).

Anyway, before leaving, one of the other med students and I hit up Safeway for a Thanksgiving feast we could prepare using only a microwave. Here was our pre-"cooked" spread:

It was actually pretty good, and it was nice to spend one last morning/early afternoon with a few other med students.

Unfortunately for me (fortunately for some of you), I bought way too many souvenirs/Christmas gifts, and couldn't get everything in my suitcases, so I had to fly in uniform. It's not too uncomfortable, but I always feel awkward with people asking if I'm coming or going, and all I can say is "coming from a month of training in Hawaii". Not quite what most people have in mind when they thank me for my service. However, it did earn me a last-second upgrade on my last flight (the 1.5 flight from Atlanta to Columbus). I slept for most of it (remember: time zones are all screwed up), but it was kinda nice.

Anyway, before I left, Tripler already had some Christmas decorations up. Well, they've had some up for the entire rotation, but the departments each had their signs up, some of which were fairly clever. Here's the department of Radiology:

And of course, I wouldn't be me if I didn't include the department of Preventive Medicine (not nearly as clever, but whatever):

So, that was that. I'm sad to see Hawaii go (I was really sad when I got off the airplane in Columbus and promptly froze). Now I have the weekend to study for the exam I should have taken on Wednesday (had I not been five time zones away), and I begin my next rotation (occupational medicine) on Monday.

Last day at work

Today was my last day in the Allergy and Immunology clinic. It was a typical day at work, albeit a bit short (no patients scheduled for the afternoon--yay!). I evaluated a couple of patients, wrote a couple of notes, chatted with COL Yang and LTC Marks for a bit, and then headed to noon conference before heading out for the day. I decided to hit the gym for what will probably be my last time swimming in an outdoor pool in November for awhile.

Anyway, here's the "office" I've been using for the past month. It's not as much an office as a storage space for extra stuff that just happens to have a computer.


So, tomorrow I have outprocessing--ugh. Walking through the hospital getting signatures from various departments (security, computer IT, etc), asking for permission to go home when I don't want it, is never my idea of a good time.

Last dive in Hawaii

Sadly, today was my last dive with Gabe and Kaimana Divers. We went out to Waianae again (on the west side of Oahu) and did two different dives than we did last week. No sunken ships or airplanes this time, but we did a cave dive and a reef dive, so there were all sorts of fish and such to see. On the first dive (the caves), we also see a sea turtle, and on the second dive, we saw a couple of octopi (?). That was rather fun, especially when they squirted ink. There's nothing dangerous about the ink; it's just to cloud the water so predators can't see the octopus, giving it time to get away (in theory).

Anyway, here are some pictures from between the dives. This is me and Jack (one of the other divers). Today was her birthday, so she got to pick the dives.

And here are some other divers. It was kinda cold today (75ish), which is why people are bundled up.

So, that's that. I got in six dives this month, which isn't bad. I just wish I knew when I'll be someplace warm enough to go diving again.

Transient hypogammaglobulinemia of infancy

No, the title of the post wasn't me slamming my hands against my keyboard. That was the disease (well, not really a disease...) one of my patients had today.

The reason why I say it isn't really a disease is that transient hypogammaglobulinemia of infancy is a normal variant of the immune system of children. When born, babies have their mother's antibodies. As the months go on, those antibodies begin to fade, and the baby's own immune system is supposed to take over. Sometimes there's a bit of a lag between those two things happening, leaving the kid with low (hypo) antibodies (gammaglobulins). So, there are low levels of antibodies in the blood (-emia), you get hypogammaglobulinemia.

The kid today was a twin born at 34 weeks (remember from my OB posts, a full-term pregnancy is anything between 37-42 weeks). Since he didn't have as much time being fed from the placenta as he should have, he didn't have as much of his mother's antibodies as he could have used, which meant his levels got lower than they should have. At Ft. Knox (where he was born), he had several ear infections starting at 3 months old, which prompted a referral to the immunologist. He did blood tests and saw that there were low levels of antibodies, so he diagnosed transient hypogammaglobulinemia of infancy. Technically, the "transient" part can't be diagnosed until it goes away, which is why he's following up now--to get blood drawn again to check the levels. Since he hasn't had many infections in the last six or so months, we're pretty sure even before getting his blood that he has appropriate levels of antibodies for his age.

On a completely different note, I've mentioned a few times the hills of Tripler, so I included the elevation map (green line on the graph) of my usual run from my GPS watch. That loop takes me completely around base--like Walter Reed and unlike Madigan, Tripler is a stand-alone base, not part of a larger one. So it's a pretty small world I'm living in this month (obviously, as there's not even a place to buy food on base).

Medical board

My first (and only) patient of the day was already in when I arrived at clinic from morning report, getting his skin tests. He was a bit unusual in that he wasn't a new patient; he had been seen by COL Yang about a year and a half ago, before he was deployed to Iraq. At that point, he was being evaluated for his deployability, due to his history of allergies diagnosed and treated by a civilian allergist since he was a teenager. Needless to say, COL Yang determined him deployable (ie, his allergies wouldn't be enough of a problem to prevent him from doing his job in Iraq).

Well, unfortunately for the patient, he got in a motorcycle accident while he was on R&R nine months into his deployment, landing him in the hospital and rehab back in Hawaii. He messed up his shoulder during the accident, and there wasn't much a motor transport operator (88M for those of you familiar with Army MOS) could do, so he's been spending most of the last year on a medical profile. When it became obvious that he wouldn't be able to do his job again, he was referred to the medical board for a medical discharge. One thing that happens on medical board is they go through your medical record (obviously) and go over everything they've seen a specialist for. So, he had to go back to COL Yang to be evaluated for his allergies again. Guess what? We discovered he still has allergies (surprise, surprise). So we refilled his prescriptions, recommended he get hypoallergenic mattress covers and pillows, and determined that while he does have allergies, it wouldn't prevent him from retention (staying in the Army), which gave him a 10% disability with the VA (from what I figure, that means they have a condition that requires specialty care, but doesn't really cause disability). Conditions are summative; if someone has five conditions that each cause 10% disability, he is considered to be 50% disabled. In the case of this patient, his shoulder/back injury from the motorcycle gives him more than enough to get his medical discharge and to get full medical care from military facilities for life.

So, my one case today was yet another example of government red tape--a man who quite obviously can't do his job requiring him to lift 200+ pounds of equipment being evaluated for the dust mite allergy that causes him to sneeze.

Rain, rain, go away...

I tried to post this last night, but the internet connection is a bit patchy, so it didn't take.

Anyway, Sunday night, a few of us grabbed a taxi down to the NEX for a quick dinner (which still took an hour...it takes awhile to get things done when you have no primary mode of transportation). While we were there, the sign said Aloha, so I decided to pass it along.

Anyway, yesterday I woke up to the sound of rain, and it didn't let up all day (or if it did, I was indoors the whole time). Fortunately, the walk from the Lodge to the hospital is a short one, because it's never fun to walk around with a wet piece of wool on top of my head. Also fortunately, rain in Hawaii is still rather warm, so while I had to start my working day in a wet uniform, at least it wasn't a cold and wet uniform.

Here's what Hawaii in the rain looks like (from the Allergy and Immunology clinic window):

Long commute to see the doctor

Yes, I know, it's been quite a few days since my last post. Unfortunately, not much has happened.

On Thursday (I think it was it Thursday), we had a patient who had quite the commute to see the allergist--all the way from Okinawa, Japan. He moved to Okinawa about two years ago, and about a year ago, began to notice a really itchy rash that instead of going away, got larger. He tried allergy medicine, tried washing his uniform every day, and tried just about everything else that people recommend for exzema. It got so bad that he was going into sick call almost every day, and had to be transferred from his job outdoors to an office job. Finall, his PA got him an appointment with the one dermatologist at Okinawa (after a few months waiting, of course). They tried him on over 20 different medicines; some made it slightly better, some did nothing. Finally, they got him an appointment with the closest allergist, which just happened to be COL Yang here at Tripler.

So we saw him and said, yep, that's exzema. So we got him some different medicines, one that he had tried and two that he had not, and then sent him back to Japan and told him to continue following up with the dermatologist. Hopefully this will take care of it. Since he can't really do his job with this exzema, the next step is to move him away from Okinawa, probably back to El Paso, TX.

Anyway, that was the most exciting patient all week (week-ish, I guess). Yesterday I walked down to the NEX at Pearl Harbor (about 4.5 miles) and did some shopping (not much, since I had to walk back). Today was another diving day. We went out of Waianae Bay, which is on the west side of the island (Tripler is close to the south). It was beautiful weather for diving while we were diving, then it instantly started raining as soon as we got the boat back to dock. Here's a picture from the boat.

I didn't get back to base until about two, and then I was tired from diving, so I didn't do much the rest of the afternoon. Then around six (when it started raining again), a couple of other students and I grabbed a cab and went down the NEX for dinner and do some grocery shopping.

Tomorrow, it's back to work, for my last (and second) full week of work at Tripler.

Back to work...kinda

After four days of vacation, it was time for me to go back to work... and I use that in the loosest sense of the word. After morning report, Dawn (the University of Hawaii med student) and I headed down to the Allergy and Immunology clinic, logged into our computers, and found that there were no patients scheduled for the day. COL Yang was working vaccine clinic in the morning and had an administration day in the afternoon, so nothing for the med students to do. He gave us the morning to study and told us to report back at 1300 for lectures on allergic rhinitis and urticaria (hives). So I did some OSU on-line lectures in the morning (as this is a required rotation), headed back for a noon conference lecture on anorexia, and then back down to clinic for two hours of lecture. In other words, it was a long day of lectures.

But here's a picture from the allergy and immunology clinic window.

North Shore

Happy Veteran's Day! Since it is a holiday, clinic was closed, which meant (another) day off from work. A couple of the other med students and I decided to drive up to the North Shore of Oahu and check out those beaches and watch the surfers.

This is no one I know, but it's the best surfer picture I got.

And of course there was sand castle building.

And then one of my fellow med students decided to demonstrate why weak swimmers should not go out too deep in the ocean when there are 5-15 foot waves. He got caught in a current and the lifeguards had to come bring him in.

So that was the last day of the four-day weekend. Tomorrow, it's back to the Allergy and Immunology clinic.

Pearl Harbor and more of the beach

Today we went in to Pearl Harbor (actually, just outside Pearl Harbor) to the U.S.S. Arizona memorial. It's actually a really neat program--there's a video about the progress of the war (in the Pacific) leading up to the events of Pearl Harbor on Dec. 7, 1941, and then a lot of stuff on that day specifically, such as which ships were destroyed, which were damaged, and which had loss of life. The most significant of those was the Arizona. When the bomb hit, it ignited the ammo (or fuel, I don't remember which), which caused a fire locking everyone inside.

Here's just about all that's left of the Arizona:

And here's the wall in the memorial with the names of those lost. There's also a section for those who made it off the ship, and chose to have their ashes buried with the Arizona after they died.

Here's a model of the ship (while it was in one piece, obviously):

And, of course, Tripler Army Medical Center from the Arizona memorial:

I have more pictures from the Arizona if anyone wants to see them (just let me know.

After visiting the Arizona memorial, I went to the NEX (Navy EXchange) on Pearl Harbor, which is the nicest exchange on the island. If most exchanges are K-mart, and the MCX at Henderson Hall was Macy's, this one is the entire mall. It was quite amazing. The commissary itself was larger than most Safeways.

And then there was the standard late afternoon trip out to the beach (Waikiki again, this time). We saw some sailboats while the sun was setting.

Tomorrow a small group of us is driving up to the northern shore of the island. I don't know what we'll see, but I hear that's where all the professional surfers go (someone said something about twenty foot waves). Should be interesting.

Vaccine reactions and long runs

So this post is a couple of days overdue, but such is life. I don't know if I mentioned this, but when I was working with COL Yang in vaccine clinic on Tuesday, I got my third Japanese Encephalitis shot (better for the taxpayers to pay than me). Well, as can happen with vaccines, especially the third shot in a multi-shot series, I got a local hypersensitivity reaction. On Wednesday, I noticed a rather large wheal (elevated swelling on the skin; think mosquito bite):

And no making fun of me for my methods of taking pictures of my arm using a phone and a mirror. Anyway. by Thursday, it changed from a wheal to a large urticaria (think one large hive).

It was incredibly itchy, but fortunately for me, I'm working in an allergy and immunology clinic, where there is plenty of Benedryl. Problem solved. By now (Sunday), the skin is still a little tender, but there's no more swelling or itchiness.

Anyway, enough with my medical issues. I wanted to go on a long(ish) run today (6-8 miles), so I looked up Oahu running trails and selected one around Diamondhead Park. Unfortunately, I not only got lost driving to the park, but also got lost while running, so my longish run turned into a bonafide long run, around 10 miles. Not so much fun with hills and tropical sun. Fortunately, I saturated myself in sunscreen first, so I'm not too burnt.

After that, I hung out at Ala Moana beach, which has really calm water, good for swimming (I did swim a bit, but I forgot my goggles, and salt water and contacts don't mix). If I get any more afternoons off, I might have to take the bus there for more swimming.

Scuba diving!

This morning I went out to Hawaii Kai to go scuba diving with Gabe, the dive master Daniel Christian dove with while he was stationed here. It was a little cloudy in the morning and a bit choppy, but once you get deeper than 10 or so feet, you can hardly feel the waves. We did two dives, a wreck dive down to about 80 feet, and a reef dive around 40 feet. Here's the picture from the boat between the first and second dive:


And here's me hanging out on the boat between dives:


After the dives, I headed back to Tripler to get the salt and the Hawaiian ocean bacteria off me (we had a noon conference lecture on skin and soft tissue infections, and apparently, there's methicillin-resistant Staph aureus [MRSA] around the islands). Then I hopped in the rental car that I deemed necessary for the four-day weekend (cheaper than taxis, but unfortunately not reimbursable) and drove to East Oahu, to Kailua beach, which was recommended to me by my friend Shannon, who was here in July. Here are some pictures from the beach:


It was still pretty windy, so the windsurfers were out in full force.


And the sun beginning to set at the beach. The only unfortunate thing I've found about being in Hawaii in November is that while the weather is pretty much the same as Hawaii in July, the sun sets around 6 pm.

After that was a trip to the Pearlridge Mall for dinner and to buy a wrist brace. Unfortunately, all the typing that I do has lead to carpal tunnel syndrome. I'm hoping that a couple of weeks of bracing my wrist while typing and sleeping will take care of the pain and I won't have to go see a doctor about it--at least until next year, when 100% of my medical care will be covered.

Both a doctor and a soldier

As Army physicians (and future Army physicians), we know that our daily lives force us serve two--or more--masters, but never had I had such a good demonstration of this as today during a rather unusual noon conference--COL Salerno, the Internal Medicine Residency Director, giving his farewell address before deployment tomorrow.

An Army doctor, even a colonel, being deployed is not an unusual event, but his story is a little different, because he is a residency director. In 2005, the Army and the ACGME (American Council of Graduate Medical Education) formed a written agreement allowing residency directors to deploy for no longer than 90 days. This was a concession on the part of the ACGME, as previously residency directors could not deploy, due to accrediting regulations that require residency directors to be on-site, supervising their residents.

That being said, COL Salerno is not going to be gone for 90 days--he'll be gone for 10 months. After several "deployment scares" that prevented him from joining various committees that would be good for his career, he decided to volunteer for deployment, to get the waiting and wondering over with. Instead of taking a simple 90 day deployment working at a CSH (Combat Support Hospital), he volunteered for a position as an administrator of an Army-Iraqi medical team (he kinda explained, but I didn't really follow). He was going to split the deployment with another colonel, which would allow him to be gone for his 90 days and return to Tripler. He had written promises from a brigadier general and the other colonel that he would only be deployed for 90 days, to avoid any problems with the ACGME. However, as things have a tendency to do with the government, it fell through. After scrambling for two months trying to rectify the situation and applying for exemptions with the ACGME, nothing changed. Since 10 months is obviously a violation of the 90 day rule, he had to officially step down as Internal Medicine Residency Director at Tripler, which was not in the career plan he had set for himself.

However, things did work out for him. When he returns from deployment in August, he'll take over as the Director of Medical Education at Madigan. I was a little sad to hear about this, which had nothing to do with COL Salerno. LTC Wiesen, the Preventive Medicine Residency Director at Madigan, was applying for that position, which would have caused a shuffle in the preventive medicine residency programs beneficial for LTC Littell and MAJ Soltis, two staff members I enjoyed working with at Madigan and WRAIR, respectively. However, COL Salerno does outrank LTC Wiesen, so it's not too surprising.

Medical education positions aren't always easy to come by in either the civilian or military worlds, but rarely do civilian physicians have to worry about what will happen if their 90 day vacation to a war zone gets extended.

Pictures

As promised, here are my first pictures from Hawaii. Dan (the HPSP student from West Virginia) and I went down to Waikiki on Sunday for dinner. Here's a picture from the beach:


And here's the Mountainside of Tripler (the two main buildings--which are connected--are called Oceanside and Mountainside). I took this on my walk up to the Tripler Lodge after work on Monday.
And more of the same from further up the hill. By the way, these hills do NOT make it fun to go running.

More pictures to come later (as I take them, of course).

It was more of the same at work today. COL Yang was doing vaccine clinic again this morning and had Dawn (the University of Hawaii fourth year med student) working with him, which left Tracie (the PA student) and I with nothing to do. After lunch and noon conference, we had one new patient, a woman with some sort of environmental irritant in the building she works in that has been preventing her from going to work. Even though the history wasn't consistent with allergies, we did skin tests on her anyway, which were, not surprisingly, negative. Chemical irritants (ie, perfume, cleansers) aren't allergies, and can't be treated with medicine like allergies. So we scheduled a follow-up (for what, I'm not sure) and sent her on her way.

After work, I decided I needed food, which is not to be found at the Tripler base, so after one of my usual laps on base, I ran to Ft. Shafter (about two and a half miles away) to visit their very small PX/Commissary before making the trek up and down the hills back.

Not sure what's on the schedule for tomorrow, but I'm guessing it won't be too different from any other day.

Free vaccines in the Allergy and Immunology clinic

Okay, technically, there are always free vaccines (at least to military personnel, dependents, and contractors) on military bases, but I saw it first-hand today while working in vaccine clinic. It was pretty fun, actually--people were lined up with their papers saying which vaccines they needed, COL Yang would chat with them for a couple of seconds, sign their papers, and send them to the Specialist to get their shots. I realized that since I'm on active duty this month, I also qualify for free shots, so I grabbed my own sheet of paper, gave it to COL Yang, and got my third Japanese Encephalitis shot, saving myself about $100, which is what it would have cost to get it at the OSU Health Center.

After a fun and exciting day in vaccine clinic, I got off work at 1500, went on a run (running up and down a Hawaiian mountain may sound fun, but it's actually hard work) and then grabbed a taxi to go into Honolulu for dinner. There is absolutely no place on base to get food--at all. There's not even a PX or commissary.

I did get a new sync cable for my phone, but it still isn't working, so there's something wrong with either the phone or the computer. Hopefully it's something I can fix.

Aloha from Tripler!

Yesterday, after a very long day of flying (hour and a half to Atlanta, nine and half to Honolulu), I arrived in Hawaii, got my two very large bags from baggage claim, climbed into a taxi, and checked in at the Tripler Lodge. During the flight, I met another HPSP student, Dan, so it was nice knowing one person on the island at least. After unpacking all the stuff I need for the month (and calling Adrienne and bragging about how sunny and warm it was), I discovered that there is no food to be found on base on Sunday nights. So Dan and I hopped on a bus toward Waikiki, wandered around the touristy areas for a bit, and had dinner at a nice Thai restaurant before heading down to the beach for a bit (can't arrive to Hawaii and not go to the beach on the first day, after all). I took pictures, but they're on my phone, and I discovered this morning that I grabbed the wrong sync cable to connect my phone to my computer, so until I get another one, no pictures from the phone.

This morning started the same as every other Army rotation: wake up, eat breakfast, wander around the hospital for a couple of hours in-processing. Then I met the chief resident of Internal Medicine and got a tour of the medicine department before he took me down to the allergy and immunology clinic. Turns out, the attending who was coordinating my rotation is now deployed, and forgot to share with the other attendings that I would be coming. Oops. So we laughed about that for a few minutes, then I went and started seeing patients.

Other than seeing a couple of patients a day in clinic, I have morning report every morning at 0730 and noon conference at 1215. There are no calls (yay!) and no weekends (yay!), so I have the evenings and weekends to myself. So far, that means I did (well, I'm still doing, technically) some allergy reading tonight, and called the dive master Daniel Christian recommended. My first dive in Hawaii is at 9 on Saturday morning, and I'm really excited about it.

End of ER

This morning was the ER exam, which meant I spent all of yesterday (with the exception of the time spent going into the medical center to get my flu shot) studying for said exam. Studying for exams usually means sitting around going over a couple hundred practice questions. Here's an example:

A 27-year-old woman with known idiopathic intracranial hypertension (IIH) presents to the ED complaining of a bifrontotemporal headache several times a day for 6 weeks after running out of her medications. She complains of occasional pulsatile tinnitus but no visual disturbances. Fundoscopic exam reveals no papilledema and normal venous pulsations. Which of the following factors determines the need for urgent treatment in patients with idiopathic intracranial hypertension?
a) The presence of papilledema on fundoscopic exam
b) A history of pulsatile tinnitus
c) Presence of an empty sella on CT scan
d) Complaint of visual loss or visual disturbances
e) A history of concomitant minocycline use

The answer is D. A short and sweet explanation is that in emergency medicine, the most top priorities are preservation of life, limb, and eyesight, so anything that threatens those must be thoroughly investigated and treated.

Anyway, so that was my yesterday, and then today I went in to the school, took my 100 question exam (which I'll get the score from in about a week), and then came back here. No plans for the afternoon, which is always nice.

Last shift in the ER

As you can guess by the title, today was my last shift in the ER. The theme for the day seemed to be "patients I have seen before". A headache patient from last week came in after passing out today. An abdominal pain patient came in with chest pain. A 15-month-old with a broken elbow came in with burns on his hands. It was like the series finale of Seinfeld, bringing back everyone who had come before.

The most interesting patient was not a repeater, however, but someone with a nail gun (I'm sure you can see where this is going...) He was working on some overhead beams while building a new house, and here is the result:

When we wiggled on it, it was stuck pretty good, so we had to do some more x-rays to prove that it wasn't going through the bone (it wasn't). If it was, we would have to ship him down to OSU for emergent hand surgery with a board-certified hand surgeon. Fortunately, since it didn't go through the bone, we just numbed up his thumb and pulled. Post-nailectomy (I made that up) x-rays proved that everything was okay. He also got a tetanus shot and some antibiotics.

So, that is the end of my ER rotation in a nutshell. Tomorrow is a fun day of studying, and then the exam is Friday at 9. Fun times.

Why adults need vaccines

Just as a warning... I'm getting on soapbox here. As a future preventive medicine physician, there are few things that I deem more important than vaccines, and few things more frustrating than seeing patients with vaccine-preventable illnesses. Despite what Hollywood mothers like Jenny McCarthy would have you believe, there is no link to vaccines and deafness or autism.

Anyway, we had two 22-year-olds come in yesterday during my shift with pertussis (whooping cough). It was a classic story for both of them, with a barking cough that comes in paroxysms (intense, uncontrollable, painful coughing for a few minutes, followed by a few hours of feeling perfectly fine, followed by more uncontrollable coughing for a few minutes). So we took throat cultures and wrote them prescriptions for azithromycin (Zithromax, or Z-pack), and then I had a little chat with them about their vaccinations, which, of course, neither of them knew. Before a couple of years ago, kids got the DTaP vaccine, which is diphtheria, tetanus, and acellular pertussis, and then adults got a booster of Td (tetanus and diphtheria) every ten years after that. However, the CDC started to notice that whooping cough was coming back, especially in adults who had gotten the full DTaP series as kids, so they changed the recommendation for adults to get Tdap (yes, the capitalization is important, but I won't bore you with the explanation) as one of their tetanus boosters.

Fortunately (?) for me, I needed a tetanus booster as part of my pre-travel vaccines, so I got my Tdap less than a month ago, which meant I "won" the debate about who got to see these two patients. When I presented my history and physical to one of the attendings, he rolled his eyes and went off on his soapbox about vaccines. Apparently, his sister-in-law is one of the Jenny McCarthy-type mothers who think vaccines will kill their children, so his nieces and nephews aren't vaccinated. Last year, the whole family had whooping cough.

So, in conclusion, GET YOUR VACCINES! If it has been more than ten years since your last tetanus booster, go see your doctor and get a Tdap, because enough people have gotten lax about that that whooping cough is coming back, and there's no need for that, since we have a vaccine that works.

Okay, stepping off my soapbox now. In happier news, they finally posted my grades from my two preventive medicine rotations, and I got honors in both :) They also upgraded my overall ratings, so I'm now a "very good" medical student, not just a "good" one. So I'm average to above average again.

Columbus Half Marathon!

This morning I got up early, had breakfast, and braved the marathon traffic to go run 13.1 miles with 12,000 of my closest friends (okay, that's not exactly true... some of them were running 26.2 miles). Here's the course map:

Adrienne is on an away rotation in Cleveland this month and had to work today, so I was on my own for the race. That's okay, because running ridiculously long distances seems to make everyone good friends. I talked to a girl running her first half before the race, chatted with some random people while running, and ran with a couple of Marines for a mile or so before they stopped for a bathroom break (they were running the whole marathon, so it's really not that impressive that I was keeping pace with them).

Overall, it was a really good race, although really cold at the beginning (my fingers were so cold, I couldn't bend them for the first two miles). I ended up breaking the two-hour mark (yay!) with a time of 1:56:17. Not my fastest ever, but it was only the second time I came in before two hours, so I'm happy. It was about an 8:47/mile pace.

Here's my medal.

And, of course, since I live right on the full marathon course, I had to be creative in driving back. Here was my route to and from the parking garage (C is my apartment):

I got to drive along High St. to get to the parking garage, but it was closed when I was headed home, so I had to get creative to drive back. I was just impressed with myself that I found an alternative route without the help of my GPS. I guess after living in Columbus for more than three years, I finally know my way around (somewhat).

Long day and new shoes

Yesterday I decided to PT with the ROTC cadets before working from noon to ten, so by the time I got home at eleven, I was wiped out and went straight to bed.

The shift itself wasn't too bad, but just like other shifts, we seemed to get the same type of patients all day--yesterday, it was lacerations. I got to do quite a lot of sewing--a head, a little finger, and an arm. One of the attendings did another arm (different patient, thankfully), and a family medicine resident did a pretty complicated laceration repair on a leg. Although I'm not all that great at suturing (it's one of those things that just takes practice, and I don't have much desire to practice it), they are nice patients to have. They have one thing wrong with them, you can diagnose and fix it there, and they go home happy. It's nothing like the abdominal pain patients, who get a huge workup which usually doesn't lead to a diagnosis, and go home feeling only a little better than they did when they came in.

Today was the expo for the Columbus Marathon (and half-marathon) tomorrow, so I went in to pick up my packet (I'm doing the half, not the whole thing), and ended up buying a new pair of running shoes. My usual shoes cost $100, and they had them for $76, so I couldn't pass that up. While I was there, I ran into a second year who recognized me from a Military Medicine Interest Group meeting, so we talked shop for a bit. It was a nice little reminder of how far I've come, and how glad I am that it's almost over.

Slow attendings and swallowed coins

The attending I worked with for the first part of my shift was very, very slow, which, of course, caused the patients to pile up. I think the average length of stay for patients this morning was over four hours. I had two patients who had been in the ER for over three hours before being seen by a physician, and that was the physician who took over at 3:00, when the first attending got off. One of them was a 17-year-old girl with abdominal pain, which the mother was positive was appendicitis (it wasn't when she was in on Monday, and still wasn't today), and the other was a 92-year-old man with congestive heart failure and a chronic cough. Both are okay and hanging out at home (I assume).

The excitement came later in the shift, when we got a 20-month-old patient with a complaint of "swallowed a penny". It wasn't the first "foreign body" complaint that I had seen (we had a few when I was doing a couple of shifts a week in the ED at Children's Hospital on my pediatrics rotation). This was the first I was handling "on my own", so I was the one ordering the initial x-rays to see where the penny was.


First of all, it looks more like a quarter than a penny to me, but that's beside the point. The point is, it's in his esophagus. Two clues: 1) in the frontal view, if you can see the face of the coin, it's in the esophagus. I don't know how they've come up with that conclusion, but it's likely based on many, many x-rays and some sort of anatomical studies of the musculature of the esophagus and trachea. 2) Also in the frontal view, you can see the airway (gray shadow that branches off, like an inverted Y), and it's not distorted by the coin. 3) In the lateral view, you can see the airway in the neck in front of the coin.

General rule is, if the kid is asymptomatic and the foreign body is in the GI tract, not the respiratory tract, you can let it pass. However, this kid was gagging and drooling, which means it has to come out. If he had been in Columbus, we would have just paged the ENTs to take it out. However, in Bellefontaine, there aren't any ENTs willing to do a foreign body removal on a 20-month-old, so this kid bought himself an hour-long trip to Columbus for a three-minute procedure at Nationwide Children's Hospital. My attending (not the slow one) wasn't happy about this. As he was saying, if he were in Alaska and there were no children's hospitals, the ER doctor would be the one taking care of it. However, since there are pediatric ENTs within a reasonable distance, it would be "irresponsible" for the ER physician to do it. Defensive medicine at its best.

Endless shifts and more class

Yesterday's shift was pretty much more of the same, with one interesting twist: instead of ending the shift with football injuries, that's how we started it. The night before, he was tackled and took a helmet to the chest, and had been having pain since, so he came in for an x-ray. Everything was fine, no broken bones or collapsed lungs, so we cleared him to continue playing.

That was our first case of the shift, and just like on Sunday, once they started, they didn't stop. I felt like I was several patients behind the entire day, but such is life. The attending I was working with wanted me to get some practice with procedures, so she had me starting my own IVs and such, which usually the nurses do. I also got to staple an 11-year-old kid's head, which was all sorts of fun. We gave him a little something to take the edge off first, so he was actually pretty still the entire time.

Today was a class day (ugh), which started with two hours of discussing ER cases. After that we had an hour of simulation, going over management of acute emergency patients with the clinical skills lab's computerized dummy. The first one ended up coding (respiratory arrest), because the student running the case kept asking the patient questions instead of noticing that the patient's (dummy's, whatever) vital signs were crashing. Fortunately, he had the rest of us backing him up, so we were able to do CPR and treat him and bring him back to life. I got in an argument with my fellow students, and the ER resident running the cases, when I said that we can give the patient O+ blood instead of O-, because studies have shown that while giving a woman with O- blood of childbearing age O+ blood can cause problems in any subsequent pregnancy, men obviously don't have the same problem. Well, the resident said he had never heard of that. When we went over the case afterwards, the attending said that I was right, and in times where you might have to conserve your supply of O-, men should receive O+ blood to save the O- blood for women. So, I was right, and they were wrong, and I was very proud of myself for that.

Anyway, after that I had to take my car to the VW dealership for its 5000 mile maintenance. I still can't believe I've put that many miles on it.

No winning the game this time

Silly me... I thought a Sunday day shift (8am-6pm) would be slow. HA! There was only patient waiting to be seen when the attending and I started at 8, but then the board quickly filled up, and never went down. I spent the entire day feeling like I was running several patients behind, because most of the day, I was running several patients behind.

For some reason, we seemed to be giving a special deal for dental pain and knee injuries. No joke. For about an hour somewhere in the middle of the day, I only saw patients with dental pain and knee injuries (and for some reason, they seemed to alternate). When I'm talking dental pain, I'm talking about really gross teeth--cavities, infections that spread to the jaw and ear, the whole bit. So they got antibiotics, phenergan (anti emetic--keeps them from vomiting the antibiotics), and the vicodin that they probably came in for.

Knee injuries aren't fun--for the patient or the emergency room physician/med student. For the patient, they hurt, and it makes it really difficult to get around when you can't put weight on your leg. For the people trying to figure out what's going on, it's pretty difficult when your primary imaging modality is an x-ray, and your primary injuries involve things that can't be seen on x-rays. Here's an x-ray of a knee with an ACL rupture:

Yeah, it's not much different from an x-ray of someone with no injury. So we did our x-rays, saw nothing, and told them to follow up with their primary care physicians to schedule an MRI.

The shift ended with the obligatory football injury (obviously, nobody told these middle schoolers that it's Sunday). Eleven-year-old boy, tried to tackle his opponent and missed, slamming his open hand into the ground and getting a buckle fracture of his radius. They're a bit subtle on x-ray. Here's an example:

His was actually a bit more obvious than that, but it did me a minute or two of staring at the x-ray to decide that it wasn't right. He was pretty excited about getting his first broken bone.

Tomorrow is a day off (yay!), which will consist of sleeping (yay!) and listening to Podcast lectures (boo!) and doing online quizzes (boo!). Ah, the busy-work... gotta love it.

On a happier note, I have my flight and hotel for Hawaii :) I'll be flying on Sunday, Nov. 2, leaving Columbus at 8 am, and staying at the Tripler Lodge (military housing right next to the hospital) until Thanksgiving (Nov. 27), when I fly back at 4 pm, getting me back to Columbus sometime the morning of the 28th.

This is educational?

As per the rotation requirements, I had to do at least one overnight shift, which I did last night/this morning. In a small rural hospital without trauma services, this was pretty pointless.

When I arrived at 11 last night, there were a few patients waiting to be discharged or transferred, and a few still waiting to be seen. So I went and saw the ones to see and gave my presentations to the attending, who was still working on transferring a patient to Columbus. The transfer took awhile, and so it was a little after 2 before everyone got out. And then...nothing. No new patients, nothing to do (unfortunately, I didn't realize how close I was to the end of the book I brought for just a situation). Finally, at around 4, the nurses took pity on me and put me in room to take a nap. They came and got me around 7 when the next patient came in.

So, I spent ten hours in the emergency department and saw a total of three patients, because I was required to do an overnight shift. If I had done those ten hours during the day, I would have seen between eight and fifteen patients, which to me seems like a much more educational experience.

Different attendings, different work

Yesterday (last night? I'm confused about time these days) I worked with an attending I hadn't worked with before. The other attendings I've worked with to date have been more of the "treat 'em and street 'em" type, which means get the patient stabilized, rule out anything life threatening or can easily fixed, and have them follow up with their regular doctor, who knows them and knows their history, in a couple of days. That's typically how emergency rooms work.

The attending last night, however, seemed more interested in finding out exactly what was going on. We had a 25-year-old woman complaining of abdominal pain, and although she didn't have an extensive history of visiting this ER, she had obviously had similar complaints many times in the past--she had already had both her appendix and gall bladder removed. Automatically at that point, you can rule out just about anything that has to be taken care of immediately--it's not appendicitis, since she doesn't have an appendix; bowel perforation is so rare in a person that age that we could probably write it up as a case report if that's what it was; and without a gall-bladder, she's unlikely to have a gallstone causing pancreatitis. Since she came in just as the previous set of doctors were coming off, they had me give her toradol (non-narcotic pain med) for the pain, get a urine sample to check for urinary tract infection, give her some IV fluids, and check a blood count and electrolytes.

No urinary tract infection, blood count showed that there was either a mild infection or mild inflammation, and electrolytes were normal. Oh, and the toradol didn't help the pain at all. By this time, the new attending had come in. He ordered IV dilaudid (narcotic pain med), a more complete blood chemistry panel, and an abdomen and pelvic CT. The more complete chemistry panel didn't show anything wrong with her liver or pancreas, the CT was normal, and the dilaudid helped "some". By this point, she had been in for over three hours, and still complaining of the pain, so the attending offered to admit her to the hospital for a more thorough workup, which she declined. When she was discharged, after getting more dilaudid, she walked out just fine, after a work-up that probably cost around $5000, which since she doesn't have insurance, probably won't get paid.

I don't think it's the role of the ER to find out the source of every ache and pain, but apparently, there are some who do. As a medical student, there's not much I can do about it except go along with whatever the attending wants to do. After all, it's their name on the chart, not mine.

Yesterday's shift

Yesterday I worked from 8am-6pm. It wasn't a bad shift; at one point we "won the game", meaning that we cleared the board and there were no patients. It happened at the perfect time, too--right at 11:00, when the drug reps were scheduled to bring in lunch (shh... don't tell Ohio State that I ate the evil drug rep's food--it's against the rules).

Nothing too exciting all day. We had a few of the typical abdominal pain patients, with nothing to diagnose. They always felt better after some IV fluids and a dose of Reglan (anti-nausea medications). At one point, every patient we had was not only related, they all lived together--a 14-year-old getting stitches removed (which should be done at the primary care physician, not the emergency department), her fifteen-year-old brother in for vomiting, and their eighteen-year-old cousin with abdominal pain.

Late afternoon/early evening on the weekdays during football season usually means the middle and high school football injuries start coming in. During my first shift last week, we had two broken arms. Today, only one football injury, a twelve-year-old who wouldn't straighten his elbow and sporting a bruise that went from his wrist to his shoulder, swollen and everything. I assumed something would be broken, and when I looked at his x-ray, I thought for sure it was broken. It looked something like this:

Although the piece on the right wasn't quite so distant from the rest of the bone. So I proudly showed it to the attending stating that it was broken, and he said, "Actually, that's the growth plate. Get a comparison film on the other elbow to see what his normal growth plate looks like." When we got the comparison films, it looked identical to the first--down to the label on everything of "left". So I thought they screwed up and x-rayed the bad elbow twice. I went in to talk to the patient, and he assured me that they x-rayed his good elbow the second time, so I called radiology, and they said they'll fix the films to have the right labels. Anyway, cutting to the chase, his elbow was not broken, he just had enough of a gap in his growth plate (as twelve-year-old boys do) that it looked like a fracture to my untrained eye.

A Saturday at Mary Rutan ED

Today I worked in the Emergency Department from 10am-8pm, a nice Saturday in the ED. Most of the cases could have waited to see their primary care physicians on Monday or Tuesday (sore foot, headache, etc), but we did have a few legitimate ED patients (although, not emergencies): a split finger that had to be sutured (I did the suturing), a fifteen-month-old with a broken elbow from last night, and a nine-year-old with a Jones fracture (break of the metatarsal of the pinkie toe). Oh, and I diagnosed the Jones fracture (with the right name and everything), so I was feeling rather proud of myself. The girl, though, is probably less excited--six weeks in a full fracture boot and crutches.

Here's an x-ray of a Jones fracture (not my patient, but you get the idea)

And, of course, there were the ones that shouldn't have gone in to see a doctor at all. We had a 21-month-old girl brought in by her mother because she got stung by a bee on her ear. No, she didn't have a bee allergy. She had never been stung before. But her ear started to swell, so her mother brought her in to make sure she's going to be okay (she is). We also had a 22-year-old girl come in with cramps. Yeah. That was fun.

Of course, there were a couple of patients that just go to show why fourth year medical students must be supervised. There was a man in his seventies with metastatic cancer, complaining of cough and chest pain. So, he got a chest x-ray, which the doctor was able to tell right away what was wrong. I could tell that there was something not right, but I had no idea what it was. The doctor tried giving me hints, but I was oblivious. It turns out that the area that looked a bit off was a Westermark sign, which is indicative of a pulmonary embolism. Here's an example of a Westermark sign:

If only my x-rays came with labels like this one... But sadly, they do not, which tells me that I have to brush up on my radiography, which does not make me happy.

Next shift... Tuesday, 8am-6pm.

Hours and hours of class

Today was a full day of didactics. I came in an hour or so early to meet with a dean to go over my MSPE (I don't really know what that stands for... medical student performance evaluation? Your guess is as good mine), which is basically a dean's letter for my residency application. Full of glowing comments about my performance and talk about how wonderful I am... and concluding with how I'm a below average medical student. Needless to say, I was not in a happy mood by the time I got to class.

The morning was dedicated to shock and ultrasound. We spent an hour and a half getting a lecture about how you can use ultrasound in shock patients, and then two and a half hours playing with the ultrasound machines. A few of my classmates had their kidneys, bladders, and hearts examined multiple times before lunch. The afternoon was one really long lecture about toxicology--three hours of going over various toxidromes and how to treat aspirin, tylenol, atropine, organophosphate, narcotic, and a few other forms of poisoning. Good times.

First shift and EMS ride-along

Tuesday afternoon/evening (2pm-12am) was my first shift in the Mary Rutan ER. Mary Rutan is in Bellefontaine, OH, which is an hour away from Columbus, so with the commute, it make for a pretty long shift--and they might be getting longer, as Dr. Mackey suggested I work ten twelve hour shifts instead of twelve ten hour shifts, to cut down on my total commuting time. I'm still waiting for that to be approved by the clerkship coordinator.

The first shift went pretty well, although it was my first time using the computer system and their electronic medical record system, so I was a bit awkward and slow on my charting. I still did manage to see several patients pretty much by myself, and got to help Dr. Mackey (and by "help", I mean be an extraneous person while he taught me how to do it) put a splint on a five-year-old with a broken arm and suture a thirteen-year-old with a cut lip. And I ended up doing two pelvic exams by myself, which I was less than thrilled with. Overall, it was a good shift, and I think I'm going to enjoy, or at least survive, the month.

After that long shift and the long drive home, arriving around 1 am, I pretty much crashed and got a few hours of sleep before my ride-along with Columbus Fire Department Medic 2, which is the busiest medic in the state. I think we had more than ten calls in the eight hours I was with them, most of which were nonsense calls (only three had to be taken to the emergency room, and two of those weren't all that necessary). It was a lot of fun, especially having a day where nothing I did was graded or evaluated, but it was also really good to see what happens with the patients before they come through the ER doors. The paramedics seemed to enjoy having us along as well, and talked about how they usually have good relationships with the doctors, because most have gone out with the squad at some point and know what goes on. Nurses, on the other hand, usually don't, and so they don't have that same understanding.

Tomorrow is a full day of class (which I'm less than thrilled with), and then I scheduled myself Friday off (which, unfortunately, will be spent studying and doing some of the online requirements for the rotation). My next shift is Saturday at 10 am.

End of DC and beginning of ER

Since I out-processed on Thursday, I had Friday free to sight-see around DC. Of course, it was cloudy and rainy, and I had already seen everything in the Mall, but I took pictures anyway.

The Washington Monument, with the Capitol in the background.

The White House.

A closer view of the Capitol. I'm not sure what's in the tent in the foreground, but when I got closer to investigate, there was a sign that said "Children's Library of Congress", whatever that's supposed to mean.
And here's the Lincoln Memorial, with the World War II Memorial in the foreground. For those of you who haven't seen the WWII Memorial, they have panels along the walls with images from the war and in the States during the war. I liked the ones with military doctors.

Vaccines and stethoscopes... yeah, that seems familiar.

Okay, these are probably medics, not doctors, but I liked it anyway.

And the Korean War Memorial. These guys have really creepy expressions on their faces up close.

They had images in the granite here as well, and I found one of a scene from a MASH (yes, like the TV show).

So that was DC... I flew back to Columbus on Saturday and spent the weekend running errands, and then I had orientation for my ER rotation this morning. It was mostly really dull lectures, followed by a suturing workshop, where they gave us ham hocks and acted as if we've never held sutures before. Great fun. My first shift is tomorrow at 2pm, and I think it's a ten hour shift, and then an hour drive back to Columbus, because I have my EMS ride-along at 8am on Wednesday. It'll be a busy first few days, but it's only three days a week for four weeks, so I think I'll be able to handle that.

Epi chiefs meeting and out-processing

There wasn't a whole lot for me to do today, so I sat in on the epi chiefs meeting at AFHSC (Armed Forces Health Surveillance Center), which is a biweekly phone conference of the epidemiology chiefs around the world--WRAIR, CHPPM (Center of Health Promotion and Preventive Medicine), USAFSAM (United States Air Force School of Aerospace Medicine), LRMC (Landstuhl Regional Medical Center), Madigan, Coast Guard, Navy/Marines Medical Command, and some other groups that I didn't catch. Anyway, a lot of time was spent talking about screening blood for Chagas disease (don't ask) before we actually got to the epidemiology part of things. There are a couple of outbreaks/clusters out there, which I found interesting, but we didn't have much time to get into them. And of course, both of the residents who were there had to leave for other meetings before this one was over, leaving me with a bunch of colonels and retired colonels to discuss the cases after the conference.

After the epi chiefs meeting was a quick lunch before I headed back to WRAIR to out-process, which consists of walking around gathering signatures--again--before turning in my badge and driving away. It was very sad, but with any luck, I'll be back here.

One of my friends from Officer Basic, Emily, is in town doing general surgery at WRAMC. Since she's on a surgery rotation, and studying for USMLE Step 2 CS, she's been ridiculously busy, so tonight was the first time she had free for dinner. It was good to see her again and talk about where everyone is applying for residencies. She's hoping to match in general surgery at WRAMC, so maybe we'll get to be interns together next year (and both so stressed we'll still never see each other... such is life).

Patient interview and journal club

Today we finally got to do our first patient interview. One of the patients is still in the hospital (actually, being transferred to the VA tomorrow, so our timing is excellent), so we got permission from the doctors taking care of him and went in to talk to him using the questionnaire that we've spent the last three weeks perfecting.

In the course of the interview, we discovered that this patient isn't quite like the others in our cluster of patients. For one, his symptoms were very sudden--he was found down in his barracks in Afghanistan and MEDEVACed to Landstuhl in Germany before being transferred to Walter Reed. Also, Stars and Stripes has already published what everyone believes to be the cause of his symptoms. Here's a link to the article:

http://www.stripes.com/article.asp?section=104&article=64432&archive=true

Well, we went through the entire interview anyway, and with any luck, the other patients in our cohort will get their interviews soon--we sent the questionnaire to the preventive medicine docs at Madigan, where two of the patients are now, and we're hoping they'll get those back to us fairly soon. With any luck, we'll find something publishable. Or, we can do what LTC Cersovsky and Dr. Scoville (the civilian epidemiologist) did a couple of years ago: publish in JAMA that they did an epidemiologic investigation of Acute Eosinophilic Pneumonia, and couldn't figure out what causes it.

That was our morning. In the afternoon we had journal club, this week's topic being rabies. I was assigned to discuss treatment of active rabies as well as to present the case of rabies being transmitted by organ transplantation. For anyone who watches Scrubs, that really did happen; they based the episode off the real-life events. It was actually a really fun journal club, because the second hour was spent discussing some cases that MAJ Soltis invented, most of which started along the lines of "That ER resident who has been calling you about possible rabies exposures all week calls you at 0300 to ask you what to do in the case of the...".

After journal club I had my evaluation session with MAJ Soltis. She said that I did such a good job, she's going to push for me to match wherever she's going to be next year. Seeing as she's trying to get sent back to Madigan, I don't know if that's such a good thing or not...